ABSTRACT
The effect of starting from the outcome and going backwards through a sequence of events is profound. Readers begin with the outcome failure. To explain that failure, Reader first reflex is often to seek other failures. The very use of the word "failure" indicates that you are still on the outside of the tunnel, looking back and looking down. The word "failure" is still popular in the probable cause statements of some investigative agencies. Reactions to failure focus firstly and predominantly on those people who were closest to producing or potentially avoiding the mishap. The proximal nature of reactions to failure means that expensive organizational lessons can go unlearned. Potential revelations about systemic vulnerabilities were deflected by pinning failure on one individual in the case of November Oscar. The flightcrew's failure to establish and maintain the proper airplane attitude and thrust setting necessary to escape the windshear.
