Monthly Archives: February 2010

Root Cause Analysis - Incident Investigation

Death of Luger at 2010 Winter Olympics

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By Kim Smiley

On February 12, 2010, Nodar Kumaritashvili, an Olympic luger from the country of Georgia, was killed during a practice run.  He lost control of his sled, flew off the track and hit a steel pole.

The investigation into the accident is still ongoing, but a root cause analysis can be started with the information that is available.  This accident obviously impacts the safety goal because an athletic was killed and it also had potential to impact the schedule goal because the track was closed during the initial investigation.

There are a number of causes that can be added to the Cause Map.  One of the more obvious causes for the accident is that the athletic was traveling at high speeds.  This occurred because the crash happened near the bottom of the track so the sled was near its top speed.  Additionally, the Vancouver Olympic track is also a particularly fast track.  Top speeds on the track were predicted to be 96 mph, nearly 6 miles faster than the standing 2000 world speed record.

How did the track get designed to be so much faster than typical tracks?  There are a number of causes that contributed to fast design.  The designers choose Whistler as the site of the track because Whistler has a colder climate than the alternatives, resulting in firm, fast ice and because there is high tourist traffic there that would help make the track a commercial success after the Olympics.  Whistler was also the site of the Olympic alpine events.

The land that was available at Whistler was long and narrow.  The site was a valley approximately 100 yards by 800 yards.  By comparison, the Calgary track was about 300 yards wide and Salt Lake City’s track was 500 yards.  Designing a track to fit in the available region meant the track couldn’t include any long curves that slow down speed as is typical.

The result was the fastest track in the history of the sport.

As the investigation continues, more details become available and they can be added to the Cause Map.

In order to ensure safety during the Olympic Games, several solutions were implemented following the accident. A wooden wall was added to the curve where the accident occurred to keep athletics on the track, the steel poles were padded and events were started lower on the track to limit the maximum speed.  The lower start was predicted to slow top speeds in the men’s events by about 5 mph.

There have been several crashes on the course since the accident, but thankfully no farther significant injuries have occurred.

Root Cause Analysis - Incident Investigation

Metro Train Derailment Washington D.C.

By ThinkReliability Staff

On February 12, 2010 at approximately 10:13 A.M., a six-car Red Line Metro train taking passengers to Shady Grove derailed near the Farragut North station in Washington, D.C.  If you’ve been reading our blog, you’ve seen our reports on three previous Metro incidents in the past year (two Metro workers were killed in January, two trains collided last November, and two trains also collided last June).

Thankfully, this derailment caused only minor injuries.  However, it did result in an extremely messy commute for a lot of people, due to a severe delay in train service.  Additionally, there was likely damage to the train and/or track, which will require labor to repair.  More labor will be required for the investigation.

All the basic information, as well as the impacts to the goals (the injuries, delay in service, property damage and labor required as a result of the incident), relating to this event are captured in a problem outline.  We can also capture anything that was different at the time.  Here we note that there were major storms in the area and that the commute was especially heavy.

Once we have completed the outline, we can begin the Cause Map with the goals that were impacted.  The impacts to the goals resulted from the train derailing.  The train derailed when the front wheels slipped and the lead car came off the track.  Metro and National Transportation Safety Board (NTSB) investigators are determining the causes of the derailment, but some of the things that will be looked at as causes include: the train was moving onto a pocket track.  Other trains previously have slipped off the track while moving onto a pocket track (a side track that allows trains to pass other trains or move around construction).  It’s unclear whether the train was moving onto the pocket track to move around other trains or track work.

As previously mentioned, the snow and icy conditions (which have been extreme as of late in D.C.) may have caused the tracks to be slippery, which potentially contributed to the derailment.  It’s possible there was damage to the tracks or switch, as the area where the derailment took place is the oldest portion of the Red Line, and is due for maintenance.  Because of an extreme budget shortfall on the Metro line, repairs to tracks and cars have been delayed.  Last but not least, there’s a possibility that the weight of the rail car may have been a factor in the derailment.  The cars were extremely crowded because of an insufficient number for the commute.  Metro was not running the normal number of cars because it had not completely recovered from the storm, but there were the normal number of commuters because the Federal Government was open.  (The Federal Government usually remains closed when the Metro system is unable to run at full capacity.)

Even though we are not yet certain which factors may have contributed to the derailment, we can include them all on the Cause Map until we are able to rule some of them out.  Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.  View the beginning stage of the root cause analysis investigation by clicking on “Download PDF” above.

Root Cause Analysis - Incident Investigation

Possible Toyota Prius Recall

By Kim Smiley

A new potential safety issue has developed and Toyota may recall the newest model of the gas electric hybrid Prius that has been sold since last May.  The National Highway Traffic Safety Administration has received 124 reports from consumers claiming that the brakes don’t engage immediately at times.  Toyota has stated that the company has received 180 reports of braking problems in Japan and the United States. The reports include 4 incidents that resulted in accidents with 2 people receiving minor injuries.

Even a slight delay in the response of car braking systems can be very dangerous because cars can travel nearly 100 feet in one second at highway speeds.

No official details are known yet on what is causing the delay in brake engagement.  In one article, a power train expert speculated that it was a software glitch caused when the hybrid switched between using the electric motor and the internal combustion engine.  In the Prius design, the same motor that is powering the car, powers the brakes.  When the hybrid is switching between motors, there might be a momentarily loss of power to the brakes during the transition.

A preliminary root cause analysis can be started using the available information.  The Cause Map can be expanded and revised as necessary as new information becomes available.  Click on the “Download PDF” button above to view the initial Cause Map.

Toyota has not stated whether a formal recall will be made.  A potential recall would affect 300,000 vehicles worldwide.

This new issue comes on the heels of a major announcement on January 21 where 2.3 million cars were recalled because of sticky gas pedals that can cause sudden acceleration. Additionally, there was a recall issued in September 2009 because there was a potential for floor mats to move out of place and cause the accelerator to stick. (A previous blog addressed this issue.)

Toyota shares dropped 21 percent following the January announcement and any farther safety issues will likely negatively impact consumer confident and stock prices.

Root Cause Analysis - Incident Investigation

Traffic Monitoring Plane Makes Emergency Landing

By ThinkReliability Staff

Just before rush hour began on Monday, February 1, 2010, traffic was stopped for a different reason – a plane landed in the median and then skidded off the road.  Thanks to quick thinking and the exemplary control of the pilot, nobody was hurt, though the plane did suffer considerable damage.  As with any incident, we can look at what happened and the effects in a Cause Map, or a visual root cause analysis.

First we record the specifics of the incident, such as date, time, place, equipment and process involved.  There’s also space to write if anything was different, though in this case it’s not clear what any differences were, so we can just enter a “?” to show we’re not sure.

Next we define the incident with respect to the organization’s goals.  Although nobody was hurt, an emergency landing (especially when the plane is damaged) has the potential to cause injuries.  These potential injuries are an impact to the safety goal.  There was significant traffic back-up after the incident, which is an impact to both the customer service and the production/schedule goal.  Last but not least, the damage to the plane is an impact to the property goal.  It’s unclear whether there was an impact to the environmental or labor/time goal, so we’ll put a “?” here, too.

Once we’ve defined the impact with respect to the goals, we can begin with those impacted goals to make our Cause Map.  The impact to the safety and property goals occurred when the plane hit trees on the side of the road.  This happened because the rear wheel of the aircraft caught in the muddy median, where the pilot landed to avoid traffic, AND because the plane made an emergency landing on the New Jersey Turnpike.  (The emergency landing caused rubbernecking, which impacted the customer service and production goals.)  The plane required an emergency landing because it was losing altitude after the loss of an engine.  (The plane was in the air giving traffic reports.)  The engine was lost because it was losing oil from a leak in the right wing fuel tank.  It’s unclear what caused the leak at this time.  The pilot chose to land on the highway because it was well lit, unlike the surrounding areas and because the traffic was light since rush hour had not yet begun.

As you can see on the downloadable PDF, a thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.  We can build a significant portion of the Cause Map even with the little information that is currently available.  Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.  (Click on “Download PDF” to view the beginning of the root cause analysis investigation.)