test post 1

I say this not to try to find blame, but to point out one of the most important facts of root cause analysis;

that the root causes of all failure are known ahead of time.

They are not known by everyone, of course. For example, the area supervisor did not know of the open oil drums ahead of time.

But the oilers did!

And the oilers in this example knew they were doing things too quickly, taking shortcuts. In fact, if you think about it

we all know of things which ought not to be happening

we all walk around in II knowledge of the root causes of all our failures