I recently came across an excellent dive into Qantas Flight 32 and the investigation into what caused the accident.
* An engine exploded
* Because a drive arm broke, allowing a turbine disk to overspeed
* Because a fire burned through the drive arm
* Because an oil pipe cracked, releasing hot oil that caught fire
* Because the wall of the oil pipe was too thin
* Because it had been misaligned by half a millimeter in the machine that manufactured it
* Because the manufacturing process required a realignment of certain clamps partway through the machining, and the part could shift during this process
* Because the correct part position had not been specified in the manufacturing documents
* Because the original manufacturing design had prevented this problem, and thus didn't need to specify a required measurement, and then the process was tweaked without catching this
* Because the product inspections were performed against the manufacturing drawings rather than the design drawings, thus no discrepancy was noticed
* Because there was "widespread procedural non-compliance" among the employees at the facility
* Because the company did not act on an internal review from 2 years earlier which had found that the facility lacked a “strong focus on quality within the business".
This is the level of investigation into root causes that you get when the people involved are competent and making a serious attempt to keep the public safe.
And the original accident didn't hurt a single person!
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Ah, so your fix is "the vibes were wrong", gotcha. Bad call. Step 7 was the failure point, but "shifting the blame" continued after that. Probably consumed hundreds of thousands of dollars and months of time to shift it that far.
I once had an argument with someone who couldn't understand why there was going to be a long investigation of a train derailment where it was obvious the train was going too fast.
"It was going too fast!"
"Yeah, but WHY?"
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This should really be a tree; I doubt most of those steps were single-cause, with no interactions (e.g. the process change alluded to).
