As a society we have difficulties with adverse events that arise from the combination of multiple factors. We want a perp, or at list a single cause, the search for which is known in the safety game as "root cause seduction." Prof. Leveson argues that "blame is the enemy of safety." By this she means that the search for a perp/root cause can impede the the search for a level of understanding that would, in turn, help prevent a recurrence. She also observes that blame is a social construct and therefore essentially a matter of opinion, depending on the legal, moral, and ethical background of the person or organization expressing it.
Analysis, on the other hand, is or should be an unencumbered, fact-base search for what happened and why. If we look at the three major factors involved in this event we find that there are precious few facts available.
The first factor is the contamination of a supply of dummy rounds, which are essentially used to decorate props and costumes, with one or more live rounds. Evidence is that the live rounds were from a group of low-power, hand-loaded training rounds previously made and used by an Albuquerque firm. We do not know how many dummy rounds were supplied, how many live rounds were discovered after the event, an whether or why there was a last-minute supplemental delivery of dummy rounds. Since the majority of the rounds ended up in gun belts, a crude estimate of probabilities shows that a purely accidental journey of a live round to the firing position in the cylinder of the weapon is fairly unlikely. Not impossible, but unlikely enough to look for other causes, such as a prank gone wrong.
The second factor is the weapon. We know practically nothing about this piece. We do not know its serial number, date of manufacture, degree of wear or state of cleanliness. The FBI has been reliably quoted as saying that
if the weapon was in good shape, a trigger pull is required to release the hammer, and that the weapon broke when it was being tested. The crucial test would be to pull the hammer of
that specific weapon back less than fully latched* and releasing it, and seeing if that would cause the weapon to fire with no finger on the trigger. We have no idea if that test was conducted and if conducted, what the result was.
The third factor is the chaotic and unrecorded interaction of individuals on the set before, during, and after the event. We are reliant on the memories of individuals, many of whom have one sort of stake or another in the outcome of the criminal and civil actions
Until we see the full results of the criminal investigation, including the full text of the FBI lab report, we are unable to perform even the most elementary analysis of causality. Which, of course, does not prevent any of us (myself included) from having an opinion.
*Usage is as shown because the site's inappropriate word filter does not like the technical term for "fully latched."
