ABSTRACT
Please put aside the industry you work in and follow along from the standpoint of the human being. In order to understand why undesirable outcomes exist, one must understand the mechanics of failure. Most undesirable outcomes are the result of human errors of omission or commission. Experience in industry indicates that any undesirable outcome will have, on average, a series of 10 to 14 cause-and-effect relationships that queue up in a particular pattern for that event to occur.
