On May 25, 2010, the National Highway Traffic Safety Administration (NHTSA) released new data about Toyota’s unintended acceleration issues, increasing the number of deaths potentially linked to the issue to 89. Additionally, the NHTSA stated that nearly 6,200 complaints regarding acceleration issues in Toyotas have been received since 2000.
The acceleration issues have already resulted in massive recalls of Toyota vehicles in the US. Nearly 5.4 million vehicles were recalled to fix issues with floor mats that could potentially shift out of position and an addition 2.3 million vehicles were recalled to repair sticking accelerator pedals. No additional causes have been found for the acceleration issues at this time, but there are a wide range of theories that include electronic issues and solar flares. Toyota denies that there are any additional causes of the acceleration at this time.
The US government is continuing to investigate the claims of unintended acceleration in Toyotas and an independent 15-month study by the National Academy of Sciences will begin in July.
A recent Wall Street Journal article discussed one of the stranger trends that have been found in the Toyota car crash data. There have been an unusual number of accidents at beauty salons.
Why beauty salons?
Just like any problem, this issue can be investigated using a root cause analysis built as a Cause Map. In this case, the Safety goal would be impacted because there is a potential for injury for both the driver and people inside the salon. Additional causes can be added to the Cause Map by, asking “why” questions and adding boxes to the right.
In this example, the article speculates that the some of the potential causes may be the age of the drivers involved (older women tend to visit salons more frequently), location of the salons (many are in strip malls near parking lots) or the architecture of salons (many have large glass windows that might distract drivers). No formal investigation has been done to determine the actual causes of this strange trend, but it is interesting to lay out the potential causes and see what factors might be contributing to the hair salon car crashes.
Click on the “Download PDF” button above to view the initial Cause Map.
On December 28, 1879, the Tay Bridge in Dundee, Scotland collapsed as an express train was traveling across. All 75 people on board were killed. The bridge had been tested and approved by the Board of Trade only 19 months prior and opened to traffic just over 2 years before the collapse. The failure of the bridge also resulted in the loss of the bridge (it was rebuilt nearby) and the temporary loss of a train route. Surprisingly, there was very little damage to the train, which was refurbished and placed back in service.
Although the bridge had passed its Board of Trade testing, problems quickly started to arise. Work crews on the bridge reported severe vibrations whenever a train crossed. An inspector noticed deficient joints, but rather than reporting them, determined he could repair them himself. (Unfortunately, it helped the vibrations but further decreased the structural integrity of the bridge.) Another train crossed the bridge at 6:00 p.m. the evening of the failure and reported a “very rough” journey – the train reportedly let off sparks as it swayed and rubbed against the guardrails.
The train that began to cross the bridge at around 7:00 p.m. was much larger and heavier than the train that crossed at 6:00 p.m. There was also severe weather, and witnesses on the shore report an especially heavy gust of wind as the bridge began to collapse. The board of inquiry determined that the collapse of the bridge was due to the failure of the tower lugs. These tower lugs were experiencing more stress than usual, more than they were designed for, due to an increase in traffic, the heavy winds, and the particularly heavy train which was crossing at the time of failure. In addition, the lugs had been weakened by fatigue cracking caused by large lateral oscillations. The causes of the additional stress were also causes of the oscillations, along with a misalignment in the track. The defective joints – both from design and from the “fix” of the inspector – allowed the oscillations to increase over the (short) life of the bridge.
This bridge failure – still the most famous in the British Isles – did lead to some additional insight in bridge construction, including some lessons still used today. By reviewing these types of failures, we can ensure that 75 people don’t have to lose their life again to get a lesson on building structurally sound bridges. To view the Cause Map of this incident, please click on ‘Download PDF’ above.
On May 1, 2010 authorities found a car bomb in a smoking Nissan Pathfinder in Times Square in New York City (NYC). The bomb had been ignited, but thankfully failed to explode and was disarmed before any damage was done.
The vehicle identification number (VIN) number had been removed from the dashboard and the door sticker, but police retrieved it from the bottom of the engine block. The VIN was used to identify Faisal Shahzad as the person who recently purchased the car. The investigation used this evidence in addition to other information to identify Mr. Shahzad as a suspect in the car bomb attempt. Early in the afternoon of May 3, his name was added to the no-fly list and an email notification was sent to airlines. In order to view the new name, airlines would have needed to check a website for the most recent no-fly list.
As the investigation continued, Shahzad was put under surveillance, but somehow eluded authorities and drove to JFK airport in NYC undetected. The evening of May 3, he bought an airline ticket and was able to get through security and board a plane traveling to United Arab Emirates. He boarded the plane approximately seven hours after his name was added to the no-fly list.
Luckily, investigators learned that Shahzad was on the plane when a final passenger list was sent to officials at the federal Customs and Border Protection agency minutes before takeoff. He was apprehended before the plane took off and is now in custody.
How was a suspect on the no-fly list allowed to board a plane headed overseas?
A root cause analysis built as a Cause Map can be used to analyze this incident. This incident is an impact to the Safety goal because a known terror suspect on the no-fly list nearly left the country. The Cause Map can be built by starting at the impacted goal and asking why questions to add causes. In this example, the suspect nearly got away because he was allowed to buy a ticket and got through security. This happened because the airline was using an outdated version of the no-fly list that didn’t include the name because it had recently been added to the list.
There are still a number of causes that are unknown in this case, but an initial Cause map can be viewed by clicking on the “Download PDF” button above.
The plan for the telescope was exciting. It was a nuclear compton telescope (NCT), built to map gamma rays, to aid in locating astrophysical objects like supernovae, pulsars and black holes. The telescope was being launched by balloon from Alice Springs, Australia for an optimal view. The NCT team had been hard at work and on April 29, 2010, eagerly awaited the launch, as did news crews and other onlookers.
However, instead of delivering the telescope to nearly 25 miles above ground, the gondola carrying the telescope left the launcher awkwardly and dragged across the ground. It hit and overturned a nearby vehicle and barely missed injuring the spectators gathered nearby. The telescope suffered major damage. The build team was devastated and will likely be spending considering effort and resources rebuilding or repairing it. As a result, all balloon launches were put on hold. (The next launch was scheduled for this month.)
Although an in-depth investigation is taking place, we can begin a root cause analysis with the information that is known so far. The near miss of injuring onlookers is an impact to the safety goal. The devastation of the build team is an impact to the customer service goal. Balloon flights on hold are an impact to the production goal. The damage to the telescope and the vehicle are impacts to the property goal. The rebuild or repair of the telescope is an impact to the labor goal. With these impacted goals in mind, we can begin a Cause Map.
The damage to the telescope occurred when the telescope was dragged across the ground. It was dragged across the ground because the balloon did not get airborne, the gondola launched improperly (as best as we can tell from the video), and the gondola was carrying the telescope. It’s likely that the high winds in the area impacted the ability of the balloon to get airborne. It’s unclear why the gondola was improperly launched – more information on this should come out through the investigation. The gondola was carrying the telescope so that it could be launched by balloon to complete its mission. A reason given for using a balloon is that it is less expensive to build and launch than an orbiter.
As more information is released regarding this incident, we can add it to our Cause Map. As NASA releases more details about what will be done to prevent future incidents of this kind, we can include these solutions