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by kube-system 740 days ago
In aviation safety investigations, all contributing factors are considered, and there are usually multiple factors involved in any incident.

My purpose of quoting that wasn't to be a wholly inclusive description of the situation (that's what the full report is for), it was to refute the above idea that engine defect was not the root cause.

> So calling this a design issue rather than an inspection issue is quite reasonable. Inspections are guaranteed to eventually fail, the aircraft being 100% dependent on them is a recipe for future disasters.

Likewise, we don't just require "good designs" instead of inspections, because even a "good design" will experience failures. In the swiss-cheese model of safety, all of the slices are important. In this case, the inspection was the first failed slice.

1 comments

> was to refute the above idea that the engine defect was not the root cause

You misunderstand what a root cause is. An accident has multiple root causes in the swiss cheese model.

Each process update is supposed to address a root cause.

This is separate from contributing factors. IE: It happened at night.