I recently spent several weeks studying an incident, trying to understand how it had happened and – more importantly – how it could have been prevented. Maybe the answer was associated with human performance, or maybe culture, or it could have been procedures, or ... well, maybe it could have been associated with any number of things. In other words, even with all of my experience and training, I had a hard time finding the singular root cause. This dilemma made me recall a question I missed on an engineer-in-training exam I took in the 1970s. The question had ladder diagrams and loop schematics and required me to determine why indicator light I-107 was off. After a long study of the supporting documents and employing all of my superior intellect, I proudly answered the question 100 miles off. Why? The correct answer was, “The lamp was burned out”; this is probably why I never became an engineer.