Thursday, January 19, 2017

The Root Causes of Anything

I'm working on a book about failure. My motto of the moment is: One person's failure is another person's revenue stream.

I found this chart in a presentation "Human Factors in Aviation" which is a summary of 86 aircraft disasters in North America by David J. Taylor

Complete Article


Causes/ major contributory factor
% of accidents in which this was a factor                   
Pilot deviated from basic operational procedures
33
Inadequate cross-check by second crew member
26
Design faults
13
Maintenance and inspection deficiencies
12
Absence of approach guidance
10
Captain ignored crew inputs                                     
10
Air traffic control failures or errors                  
9
Improper crew response during abnormal conditions
9
Insufficient or incorrect weather information
8
Runway hazards
7
Air traffic control/crew communication deficiencies
6
Improper decision to land
6


So is it not clear that these can be grouped into five groups? Human, Procedural, Mechanical, and Environmental, with a side order of Detection Issues?

And of all of these do they not boil down to human, at some point?




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