January 23, 2006 | Mark Paradies

Monday Accident of the Week – Unfortunate Accident – Combination of Circumstances

C-130~Mishap

The announcer says that this “unfortunate accident” was caused by a “combination of circumstances.”

How do you understand the combination of circumstances that lead to an unfortunate accident?

You must understand “what happened” before you can understand “why it happened.”

That is why we draw a SnapCharT(R) to graphically show the sequence of events before we use the Root Cause Tree(R) to find the root causes of the Causal Factors that combined to cause an accident.

Want to learn more about the TapRooT(R) Process?

1. Read more at:

Usingtaproot (How Do You Use TapRooT(R) Paper)

2. Attend TapRooT(R) Training.

3. Attend the TapRooT(R) Summit.

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