On a Saturday morning in the summer of 1966, Vinton Bacon, general superintendent of the Metropolitan Sanitary District of Chicago, pulled his car into a service station near his suburban home for gas and an oil check. The attendant found four sticks of dynamite wired to the car’s engine. Only a faulty connection prevented them from exploding.
A commentary that says too often, when we investigate safety incidents, we focus on the immediate cause and not the “root cause.” They aren’t the same thing.