[masraum]

Originally Posted by sc_rufctr

Thanks but at the end of the day a live round found its way into a prop gun.

Had that not happened we wouldn't be having this conversation.

- Unless "Baldballs" in a fit of rage (which he's famous for) smashed someone in the head with it!

that was kind of the point of that article. I should have only posted the one liners.
I bolded certain items. It's pretty natural, I think, for us to always look for a cause or single factor that was responsible, but in systems like this where there are multiple layers of security, there's not any one cause (unless maybe there's been a single action that removed the system entirely). In this case, it seems that the system was in place, but there were at least 3-5 failures in the system that ultimately lead to this catastrophe. 1 live ammo on set 2 live ammo in the gun at times 3 armorer not on set when the gun was produced/handled/used 4 gun not cleared etc...

1 Complex systems are intrinsically hazardous systems
2 Complex systems are heavily and successfully defended against failure.
3 Catastrophe requires multiple failures – single point failures are not enough.
4 Complex systems contain changing mixtures of failures latent within them.
5 Complex systems run in degraded mode.
6 Catastrophe is always just around the corner.
7 Post-accident attribution accident to a ‘root cause’ is fundamentally wrong.
8 Hindsight biases post-accident assessments of human performance.
9 Human operators have dual roles: as producers & as defenders against failure.
10 All practitioner actions are gambles.
11 Actions at the sharp end resolve all ambiguity.
12 Human practitioners are the adaptable element of complex systems.
13 Human expertise in complex systems is constantly changing.
14 Change introduces new forms of failure.
15 Views of ‘cause’ limit the effectiveness of defenses against future events.
16 Safety is a characteristic of systems and not of their components.
17 People continuously create safety.
18 Failure free operations require experience with failure.