Monthly Archives: April 2013

Root Cause Analysis - Incident Investigation

The 8 Worst Typos Ever Made

By ThinkReliability Staff

When we perform a root cause analysis, we occasionally find that something as seemingly minor as a typo has had a huge impact on an organization’s bottom line, their reputation, or even public safety.  The following is a collection of some of the worst typos ever made, with respect to impacts to the organization’s goals.

8. Misspelling your own name 

The Oops: In 2008, a New Hampshire newspaper misspelled its own name, in the front page title, specifically by adding an extra “s”.  Missouri State University misspelled its own name on bags provided to students (Univeristy [sic]).  The error was pointed out by a student.  However, the most well-known of this kind of error probably occurred when “Chile” was misspelled on their 50-peso coin.  The misprinting occurred in 2008, but was not noticed until late 2009.  (Rather than CHILE, the coin said “CHIIE” [sic].  The coins are now collectors’ items.)

The Impact:  The general  manager of the Chilean mint was fired for the coin error.  In the newspaper and university cases, actual cost was minimal and the main impact was abject embarrassment.  However, typos can frequently result in loss of opportunities.  Some recruiters have said that when they get multiple submissions for a single job, resumes with errors go straight to the shredder.

7. Counting on a computer to do your job for you 

The Oops: On January 7, 2009, the US Army admitted that 7,000 letters addressed “Dear John Doe” were sent out to family members of soldiers killed in Iraq.

The Impact: The Army immediately issued a formal apology and sent a personal note to the families.  The letters were sent to the correct families, but there must have been a devastating moment for the families when they thought they may have received someone else’s letter . . . and then realized they hadn’t.

6. Entering the wrong number 

The Oops: On February 5, 2011, an employee at a company in Japan listed 610,000 shares of a job recruiting company at 1 yen apiece.  What it really meant to do was list 1 share at 610,000 yen (~$5,000).  A surprising number of similar stories abound, including a listing on April 5, 2006 for flights from Canada to Cyprus for $39 CAD, instead of $3,900.

The Impact: Although the company in Japan tried to cancel the order, it was processed by the Tokyo Stock Exchange, resulting in a loss of $225 million.   In the case of the surprisingly cheap airline tickets, they were honored by the airline (after initially trying to cancel the tickets) to 500-2000 people, resulting in a very expensive typo indeed.

5. Incorrect punctuation 

The Oops: A communications company in Canada thought it had a five-year deal beginning in spring 2002 with a utility company to add cable lines to thousands of utility poles.  Then the utility company cancelled in early 2006.  The Canadian Radio-television and Telecommunications Commission determined that, because of an extra comma, the contract said that the contract could be cancelled with one-year’s notice, even during the first five years.  (The area in question said the contract: “shall continue in force for a period of five years from the date it is made, and thereafter for successive five year terms, unless and until terminated by one year prior notice in writing  by either party.”)  A missing hyphen in the coded computer instructions was partially responsible for the loss of steering on Mariner 1, which was launched on July 22, 1962.

The Impact: After the cancellation, the utility upped its rates for the use of the poles, which will result in the communications company paying about $2.13 million more than it thought.  But if you think that’s expensive, even worse was the loss of Mariner 1, which had to be blown up when it could no longer be steered.  The value of the Mariner 1 in 1962 was $18.5 million.

4. Using the wrong units 

The Oops: The Mars Climate Orbiter was lost on September 23, 1998 while trying to establish orbit around Mars.  Turns out the trajectory was lower than expected (allowing the orbiter to be subjected to the extreme heat of the Martian atmosphere) because incorrect velocity changes were used in calculations.  Specifically, results from a software program were provided in pound force (English System of Units) and the program predicting the velocity assumed the results were  in Newtons (International System of Units, or SI), a factor of difference of 4.45.  (Read more about the Mars Climate Orbiter.)

The Impact: The Mars Climate Orbiter was destroyed with a complete loss of mission.  The orbiter cost $125 million in 1998.

3. Leaving out a (very important) word 

The Oops:  The interesting thing about some small words (like “not” or “out”) is that they change the meaning of the entire sentence.  A man named Bruce Wayne Morris (who does not become Batman) was sentenced to death in 1987 after the jury was given the choice of death or prison for life with the possibility of parole.  The choice was in fact between execution or a life sentence without parole.

The Impact: Morris’ death sentence was reversed by a federal appeals court in 2001 – that’s right, 11 years later.  (The cost of 11 years worth of deliberation and appeals is not known.)  It is thought that the jury originally opted for the death sentence rather than worrying about him being released on parole at some point in the future.

2. Checking the wrong box 

The Oops:  On January 28, 2013, Evan Spencer Ebel was released from jail, the result of a clerical error.  In 2008, while serving eight years, Ebel pleaded guilty to assaulting a prison guard.  The additional sentence was to be served after the original eight-year sentence.  Instead, the record indicated that the second sentence was to be served concurrent with the original sentence.

The Impact: Ebel is believed to have murdered a pizza delivery man on March 17 and the executive director of the state Department of Corrections on March 19 before he was killed by deputies in Texas on March 21.  A similar situation also ended in tragedy when Charles Anthony Edwards III was mistakenly discharged  in January 2012 from a high-security mental hospital in California, where he is suspected of fatally stabbing a shop owner.

1. Writing illegibly 

The Oops:  While bad penmanship may not necessarily be considered a typo, it can result in the same kinds of problems.  Bad penmanship means that the person who has to read it is much more likely to read it incorrectly.  In one such case, the registration for a ship’s Emergency Position Indicating Radio Beacon (EPIRB) was written sloppily, and a “C” become a “0”.  This didn’t much matter until more than two years later, on March 24, 2009, when the ship (Lady Mary) began to sink and set off its EPIRB.  Because the code was entered incorrectly, it took more than an hour and a half to locate the ship.

The Impact: By the time the Lady Mary was reached (the delay was due to other compounding errors as well), only one crew member was able to be saved.  The other six men were lost at sea.

What to do so this doesn’t happen to you 

When something is important, give it an extra edit.  Specifically, find someone who is not a coworker (a coworker will likely gloss over the same things you did, like the name of your organization).  Motivated teenagers make great editors.  Offer them a dollar for every error they find.  (It’s well worth it.)

Note that legal documents, given the importance of their exact wording and difficulty changing any whoopsies, should be extra, extra carefully edited.

If you really don’t have time to get an independent edit, try reading it out loud.

When your computer is doing some of the work for you, it’s probably a good idea to actually look at a few of the results.

When you’re working with numbers, which are much more difficult to check for errors than words (“univeristy” [sic] is not a word, but 39 is still a number), perform a related math calculation.  One that in particular could have come in handy here is the percentage reduction in the cost of the item.   (Plane tickets at 99% off?  Maybe you want to look at that one again.)

Also, your math teachers weren’t kidding about always using units with your numbers.  Or else you might as well answer the question “How far is it?” with “10”.  If at any point in your analysis a different unit of measurement comes up, go ahead and write both, the way many cookbooks and measuring cups now contain both ounces (English System of Units) and milliliters (Metric System of Units).

All the editing tips above may help, but maybe more important is an understanding of the possible impact of a seemingly innocuous typo.  Yes, they happen to everyone.  But before you let them out of your office, take another look.  If someone thinks you’re wasting your time, show them the two million-dollar examples above.

I’ve made a handy sheet to remind you why you care about editing.  To take a look and print it out for your wall, please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Deadly Explosion at Texas Fertilizer Plant

By ThinkReliability Staff

An explosion at a fertilizer plant in West, Texas, destroyed much of the town and killed between 5-15 people.   (Search and rescue is still ongoing.)  At least 160 were injured but that number may increase.  The material involved in the explosion was ammonium nitrate, a popular fertilizer.

Capturing the impacts to the goals as a result of an issue is essential to understanding the true effect.  In this case, the fatalities and injuries were severe.  The property damage, which included the plant, as well as the homes of more than 100 families, was also extensive.  An environmental impact resulted from the release of ammonia, which is a respiratory irritant. There was some level of evacuation, which can be considered an impact to the customer service goal, though the high number of injuries has led some to believe the evacuation was not widespread enough.  Additionally, ongoing search and rescue, and firefighting operations are an impact to the labor goal.

These goals were all impacted due to the explosion at the fertilizer plant.  Ammonium nitrate can explode when ignited at very high temperatures.  In this case, a fire provided the high heat.  We can capture these causes in a Cause Map, or a visual form of root cause analysis.  The cause of the fire itself is as yet unknown, though if that is determined we can add it to the Cause Map as well.

What is known is that efforts to prevent explosion were ineffective.  The plant did not believe that an explosion was possible.  Its internal safety review had a worst-case scenario of a ten-minute ammonia release, causing no injuries.  It is fairly rare that ammonia nitrate explodes; only 17 known cases of unintended ammonia nitrate explosions resulting in fatalities have occurred since 1921.  Firefighters were on scene fighting the fire when the explosion occurred, leading to many responder fatalities and injuries.  Oversight at the facility was limited; OSHA has not inspected the facility for at least the last five years.

It is worth exploring why large amounts of ammonium nitrate were present.  Ammonium nitrate is an inexpensive, effective fertilizer.  It is particularly good at delivering nitrogen to food-bearing plants, like fruit trees.  The use of nitrogen greatly increases the yield of food from these plants.  (It is said to increase the carrying capacity, or number of people who can be supported by a hectare of land – from 1.9 to 4.3.)  Given the shortage of food-growing land, this is certainly important.   However, the benefits must be considered alongside the risk and certainly in the future more oversight of these types of facilities may be needed to protect the public from the process as they benefit from the results.

To view the Outline and Cause Map, please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Seat Belts: A Simple Solution That is Still Underused

By ThinkReliability Staff

One of the most frequent questions we get is “What’s the root cause?”  The problem with that question is that there is never just one, root cause.  Rather, the ‘root cause” should be thought of as a system of causes, much like the roots of most plants are a system.  But the idea of a root cause is attractive – only one thing to find, analyze and solve.  There are a few, rare situations that are almost one, root cause.  One of them is the use of seat belts.

Not wearing a seat belt can cause all kinds of problems, in any kind of vehicle.  In passenger vehicles, seat belts saved more than 75,000 lives from 2004 to 2008, according to the National highway Traffic Safety Administration (NHTSA).  Over that same period, more than 26,000 more lives WOULD have been saved if everyone wore a seat belt.  Unfortunately, not everyone does.  According to the National Safety Council (NSC), seat belt use varies by the type of vehicle but is around 80%.

It’s not just cars that are at issue.  On March 29, 2013, a man was thrown from an experimental plane and killed when the canopy came off.  He wasn’t wearing a seat belt, which would have almost certainly kept him from being ejected – and killed.  Although the FAA requires that safety belts be fastened while crewmembers are at their duty  stations, the pilot, who was killed, had unfastened his safety belt to troubleshoot problems with the battery and apparently did not successfully re-fasten the belt.   (The instructor was not ejected and was able to safely land the plane.)

Although states are trying with mandatory seat belt laws, you can’t force everyone to wear a seat belt all the time.  However, there are many actions being taken to try and increase seat belt use.  As previously mentioned, states are increasing laws and enforcement of requiring seat belt use for all passengers.  Car manufacturers have added warning systems that encourage seat belt use for drivers, and front seat passengers.

Seat belt use (percentage-wise) is lowest among those who have just gotten their license.  As a parent, requiring use of a seat belt every time, every trip, for every passenger can help reduce the risk to your child and his or her passengers.  As an employer, vehicle crashes can have a serious impact to your organization. According to the Occupational Safety and Health Administration (OSHA), motor vehicle accidents are a leading cause of death and injury and cost employers $60 billion annually.  All employers should have a driver safety program.   (Tips on establishing a driver safety program can be found here.)

There is no question that deaths from traffic accidents are a major concern – to everyone.  According to the NHTSA, “seat belts are the most effective traffic safety device for preventing death and injury.”  Because of the effectiveness of seat belts, the  risk of deaths from vehicle accidents, it’s no stretch to say that buckling your seat belt – and getting everyone in your vehicle, family, and organization to do the same – may well be the most important thing you do today.

To view the Outline and Cause Map for the plane ejection, please click “Download PDF” above.  If you’re curious why school buses do not have seat belts, read our previous blog.  Or click here to  read more:

This incident

NHTSA

NSC

FAA

OSHA

Root Cause Analysis - Incident Investigation

The Deadliest Airship Crash in History Wasn’t the Hindenburg

By Kim Smiley

Many people have heard of the Hindenburg, but have you heard of the USS Akron?  The Hindenburg crashed in 1937, killing 35 people. The USS Akron crash four years earlier killed 73, making it the deadliest airship crash in history.

The crash of the USS Akron can be investigated by building a Cause Map, a visual format for performing a root cause analysis.  A Cause Map is built by asking “why” questions to determine what causes contributed to an issue.  The causes are organized on the Cause Map to illustrate the cause-and-effect relationships between them.  Why were 73 people killed?  This occurred because they were onboard the USS Akron, the airship struck the ocean surface, the crew had little time to brace for impact and there were insufficient flotation devices onboard.

The crew was onboard the USS Akron because the airship was operated by the US Navy and was performing a routine mission at the time of the crash.  The airship hit the ocean because it was operating over the ocean and lost altitude in a severe storm.  Why was the airship operating in a storm?  There was no severe weather predicted at the time and a low pressure system unexpectedly developed.  The crew had little time to brace for the impact because they weren’t aware that an impact was imminent.  There was low visibility at the time because it was a stormy, dark night. The barometric altimeter was also showing that the airship was higher than it actually was.  Barometric altimeters are affected by pressure and the low pressure in the storm impacted more than the crew realized.   The lack of life jackets and other floatation devices also contributed to the high number of deaths.  There were no life jackets onboard the airship at the time of the crash and only one rubber raft.  The safety equipment had been given to another airship and had never been replaced.

While few of us plan to operate or build an airship anytime in the near future, the important of keeping sufficient safety gear onboard any vehicle of any kind is an important lesson.  Lack of safety gear is a reoccurring theme in many historical disasters.  For example, the sinking of the Titanic would be a very different story if there had been sufficient lifeboats onboard.  This example might be very different if the crew had been wearing life jackets.  The airship would still have been lost, but there would likely have been fewer casualties.

To view a high level Cause Map of this example, click on “Download PDF” above.