The Tragic Truth – A Cause is a Cause is A Cause is A Cause.

Canadian Transportation Safety Board Publishes Its Report

On The Lac-Mégantic Rail Disaster

http://www.forbes.com/sites/stevebanker/2014/08/19/canadian-transportation-safety-board-publishes-its-report-on-the-lac-megantic-rail-disaster/

 

The wisdom of the pictorial “cause diagram” is that there is NO LONGER a need to label any, some, all CAUSES as subclasses. They all contributed and they are ALL contributing factors! GREAT JOB TSB! No let’s see what we can do to create BETTER safety on our Railways!

Best of all the dominoes have disappeared!

http://www.tsb.gc.ca/eng/enquetes-investigations/rail/2013/r13d0054/r13d0054.asp

 

accident

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