Monthly Archives: January 2011

Root Cause Analysis - Incident Investigation

Is a College Education Worth the Price?

By Kim Smiley

Most students go to college hoping it will further their education and allow them better career opportunities upon graduation.  But is the investment of time and money required to get a college education worth it?

The cost of college has been rapidly increasing over the last several years.  At the same time, many company executives have been noting that today’s students do not graduate college with the critical thinking skills necessary to succeed.  A new book, “Academically Adrift: Limited Learning on College Campuses,” by sociologists Richard Arum of New York University and Josipa Roksa of the University of Virginia publishes findings of a study that says that students aren’t improving much in the areas of “critical thinking, complex reasoning and writing” during their four years in college.

The study based its results on assessment scores taken by 2,300 students as they entered college, after two years, and after four years.  After two years, 45% of students showed insignificant improvement and after four years, 36% showed insignificant improvement.  The study also found that very little reading and writing is required in many college courses.

The findings indicate that students aren’t being adequately prepared for their future careers.  How do we solve this problem?  Similar to engineering problems, a root cause analysis could be performed to help understand and hopefully solve this problem.  The more clearly a problem is understood, the easier it is to develop and implement solutions.  There are some potential solutions that have been suggested already, but only time will tell if they are successful.

Many institutions of higher learning are working to combat the issue.  More than 70 college and university presidents have pledged to take steps to improve instruction and student learning, and make those results public.  Hopefully the colleges and universities that have pledged to use evidence-based solutions to improve learning will pave the way for all colleges and universities increasing the critical thinking and writing skills of all college graduates.

There are also a number of things that students can do to improve their own learning.  The study found that students who study alone (as opposed to in study groups) are more likely to post gains over college.  Additionally, students who choose to read and write more, and attend more selective schools that focus on teaching rather than research tend to improve their critical thinking and writing skills over their years at college.

Everyone should agree that a large percent of students graduating from college showing little or no improvement in critical reasoning and writing skills is not a desirable outcome – i.e. a problem.  There are many ways to improve the situation.  Some of these solutions must be implemented by the universities themselves, but students can take many actions themselves to increase their learning over their college years.

Click here to read more about this topic.

Root Cause Analysis - Incident Investigation

More Info about Deadly Mine Explosion

By Kim Smiley

Around 3 pm on April 5, 2010 in Montcoal, West Virginia, a huge explosion rocked the Upper Big Branch South mine killing 29 (Click here to read previous blog on the topic).  The toxic gas concentration in the mine remained so high after the accident that Mine Safety and Health Administration investigations were not able to enter the mine for more than two months after the accident.  The final report is still two to three months away, but the MSHA has developed a working theory on what caused the mine explosion.

According to a recent NPR article, investigators believe they have found the source of the spark that started the chain of events that lead to the massive mine explosion.  A longwall mining machine was in operation inside the mine, creating sparks as it ate through both coal and sandstone.  Sparking may have been worse than usual because investigators found that the carbide tipped teeth on the machine were worn down so that bare metal was contacting the stone and coal.

Sparks are expected during these types of operations so a water sprayer system is typically used to prevent explosions from occurring, but investigations found the water system in Upper Big Branch was not functioning properly.  Additionally, a properly functioning water spray system would help control the amount of coal dust in the air.  Coal dust is an accelerant, which means it will contribute to an explosion if ignited.

Another cause of this accident is the level of methane gas in the environment.  The Upper Big Branch South mine is a particularly gassy mine that naturally emitted high levels of methane gas.  There are still some open questions about the role ventilation may have played in the accident.

Small ignitions of methane gas are not uncommon in coal mines, but large explosions are rare.  According to data collected by Mine Safety and Health News, about 600 ignitions have occurred in the past 10 years without any major mine explosions occurring.

Coal mining involves managing a tricky combination of coal dust, methane and sparks.  Usually, no one gets hurt, but in this case the mixture resulted in a massive explosion that traveled more than two miles inside the mine and claimed the lives of 29.  Performing a thorough root cause analysis can help investigators understand what was different in this case and hopefully help the lessons learned be applied to other mines.

As more information comes available, the Cause Map can be expanded to include all relevant details.  Click “Download PDF” above to view the intermediate level Cause Map for this example.

Root Cause Analysis - Incident Investigation

Why Don’t All School Buses Have Seat Belts?

By Kim Smiley

Nearly every state in the US has a law requiring seat belts to be worn in cars. The lone state that doesn’t require adults to wear seat belts, New Hampshire, still has a law requiring children under 18 to wear seat belts.

Currently, only 6 states require seat belt in school buses.  The federal government does not require seat belts to be in installed in buses weighing over 10,000 lbs.  The regular school buses that make up 80 percent of the buses in this country exceed this weight limit and most do not have seat belts.

So if seat belts are required by law in cars, why don’t all school buses have seat belts?

Like most engineering problems, this isn’t as simple a question as it first appears.  The main reason that seat belts aren’t required on all buses is that buses are fundamentally different from cars.

School buses are heavier and taller than cars.  During an accident, a passenger on a bus experiences less severe crash forces than an occupant of a passenger car.  The interior of a modern school bus is designed to protect passengers passively through something called compartmentalization.  The seats are strong, closely-spaced, high backed, and covered in 4 inch thick foam to absorb energy.  The passenger is protected by the cushioned compartment created by the seats.

Buses are considered to be the safest form of ground transportation.  According to the National Highway Traffic Safety Administration, buses are approximately seven times safer than passenger cars or light trucks.

But would seat belts make them even safer?

This is subject to debate.  There are groups pushing for the federal government to require seat belts on all buses.  Others believe that the potential for misuse and incorrectly worn seat belts would actually result in a higher risk to safety if seat belts were installed.  There are also practical considerations like finding funding in cash strapped budgets to install seat belts and to buy the extra buses that would be necessary since fewer students can be accommodated on a bus with seat belts than one without.

There are few topics touchier than the safety of children and no clear cut answers to the question of what constitute a design that is safe enough.  It could be useful when dealing with a problem like this where emotions might run high to document all information in a Cause Map.  A Cause Map is a visual root cause analysis that incorporates the information associated with an issue in an easy to read format.  All pertinent evidence and facts associated with the topic can be recorded.  Having the same facts available to all invested parties can help keep the discussion production and uncover the best solutions.

To learn more about school bus safety, please visit the National Transportation Safety Board website and National Highway Traffic Safety Administration website.

Root Cause Analysis - Incident Investigation

Metrodome Collapsed

By Kim Smiley

At about 5 am in the morning on Sunday, December 12, 2010, the roof of the Metrodome collapsed under the weight of snow accumulated during the heaviest snow storm in almost two decades.  According to the National Weather Service, Minneapolis received a whopping 17.1 inches of snow between Friday and Saturday night.

The Metrodome is home to the Minnesota Vikings and its collapse set off a multicity scramble as the NFL worked to reschedule the Monday night game between the Vikings and the Giants that was planned to take place in the Metrodome on December 13.  After considering all the options, the game was moved to Detroit.  (Ironically, this was the first Monday night game played in Detroit in a decade because of the Detroit Lions’ abysmal record.)

Despite some early optimism, the latest update is that repairs will not be completed until March. The damage to the Metrodome moved the last two games of the Vikings’ season and will impact the schedule of about 300 college baseball games along with many other events planned in the venue.  In addition to the massive schedule impact, the cost associated with the repairs will be significant.

Why did this happen?

A Cause Map can be started using the information that is known.  To build a Cause Map, begin with the impacted goals and add Causes by asking why questions.  In this case, the impacted goals considered are the Production-Schedule goal and the Safety goal.  Fortunately, there were no injuries during the collapse, but the impact to this goal is included because of the potential for injuries if the Metrodome collapsed while occupied.  Click on the “Download PDF” button above to see the initial Cause Map built for this example.

The Metrodome design includes an inflatable dome to protect the venue from the harsh Minnesota winters.  The massive amount of snow accumulation on the dome after the severe storm exceeded the capacity of the dome to stay inflated.  The dome is made of two layers of materials (the outside layer is Teflon coated fiberglass and the inner layer is made from a proprietary acoustical fabric) and air is constantly pumped into the space between the layers to keep it inflated.  The massive weight of the snow tore the roof in several places and it collapsed.

The high winds that accompanied the snow fall were also one of the causes contributing to this accident.  When there are heavy snow falls, workers typically climb on the roof of the Metrodome and use steam and high powered hot water hoses to melt snow and limit accumulation.  Workers were unable to access the roof due to safety concerns because of the strong winds.  Additionally, the other measures used to prevent accumulation were inadequate.  These measures include pumping hot air into the dome and heating the stadium to about 80 degrees to help melt snow.

To view a video of the Metrodome collapsing from inside dome click here.