Monthly Archives: July 2014

Root Cause Analysis - Incident Investigation

Loss of Flight 17 over Ukraine

By ThinkReliability Staff

On July 17, 2014, Malaysian Airlines flight 17 was shot down 33,000′ above Ukraine by a surface-to-air missile.   The issue can be looked at in a Cause Map, or visual root cause analysis. Clearly the primary impact to the goals in this case was the death of all 298 passengers and crew members on the plane. Next the Cause Map is built by developing the cause-and-effect relationships by asking “Why” questions.

While there are multiple issues that can be discussed related to why the missile was fired at the plane, the solutions that would result in missiles not being fired are outside the sphere of influence of most (if not all) of us. Focusing on the solutions that are within the sphere of influence of airlines, regulatory bodies, and even individual passengers allows the most effective use of time.

For this reason, we will focus on why the plane was in the area. The route that planes take is generally determined by wind, weather and congestion. There are also areas where airspace is restricted. At the time Flight 17 flew over Ukraine, the restricted airspace over the area ended at 32,000′. Just a week prior a military transport plane was shot down at 21,000′. However, the primary concern at the time was shoulder-fired missiles which generally have a range much less than 32,000′.

Beyond the political questions of what to do about an unprovoked attack on a commercial airline, airlines, their regulatory bodies, and even passengers are trying to determine how they can stay safe while flying near or through one of the 41 currently designated “kinetic conflicts” (essentially areas where people are shooting at each other, causing a potential risk to planes, though generally not those flying at typical levels of commercial airliners).

Regulatory bodies, including the International Civil Aviation Organization (ICAO, the air-safety arm of the United Nations), are now looking at “the respective roles of states, airlines and international organizations for assessing the risk of airspace affected by armed conflict.” Currently each government determines the risk and whether airspace should be restricted. Air-safety experts say Ukraine’s restrictions weren’t unusual. Says air-safety consultant John Cox, “There has never been an airliner shot down from a surface-to-air missile at this kind of altitude. The threat has always been a shoulder-fired missile from insurgents.”

Individual airlines are also considering what they can do to reduce their risk. Some airlines are even considering antimissile devices, which use laser beams to draw heat-seeking missiles away from the plane itself. However, these are only effective against shoulder-fired heat-seeking missiles, not the type of missile that brought down flight 17. While many countries use these types of protection for their military planes, only Israel has required their use on commercial airliners.

For individual passengers who are concerned about the route their plane may be taking, flight-tracking services will allow them to see the flight paths of the most recent flights. However, because of gaps in coverage, flight paths over certain areas (such as over North Korea) may not be accurate. Airlines are being pressured to release their typical flight paths.

Even with the attack on flight 17 and the loss of two other planes (TransAsia Airways 222 and Air Algerie flight 5017 crashed on July 23 and July 24th, respectively, both in remote areas in poor weather), industry experts assure passengers that flying is still safe and that crashes are declining worldwide. The aviation accident rate is 2.8 per one million departures, the lowest since ICAO started tracking numbers. So far in 2014 there have been 70 commercial-plane crashes compared to 81 for the comparable period last year. (There were a total of 90 commercial flight crashes in 2013, compared to 99 in 2012 and 118 in 2011.) According to director of safety at aviation consultancy Ascend, “Having three accidents together doesn’t tell you anything about safety. It’s about the long-term trend. Airline safety is improving, and it is generally improving faster than the industry is expanding.”

To view the outline, Cause Map, and solutions, please click on “Download PDF” above. Read about more aviation safety incidents:

Malaysian Airlines Flight 370

Air Traffic Control system confusion affects hundreds of flights

Smoke at FAA facility results in flight disruptions

Asiana flight 214

Root Cause Analysis - Incident Investigation

Deadly Moscow Metro Derailment

By Kim Smiley

On July 15, 2014, a routine morning commute on the Moscow subway quickly became a nightmare when a metro train dramatically derailed, resulting in 23 deaths and about 150 injuries.  A massive rescue operation took hours and the investigation into the incident promises to be lengthy as well.

The investigation into this horrific accident is still ongoing, but an initial Cause Map can be built to capture the information that is already available and the Cause Map can be expanded as more details are known.  A Cause Map is a format for performing a visual root cause analysis.  The first step is to define the problem by filling in an Outline with the background information for the incident.  Additionally, any different or unique elements are documented because differences should almost always be investigated.  The impacts to the overall goals are documented on the bottom half of the Outline.  Once the problem is defined, the analysis is performed by asking “why” questions and using the answer to build the Cause Map. (To view the Outline and an initial Cause Map for this accident, click on “Download PDF” above.)

This safety goal was clearly impacted in this example because of the fatalities and injuries.  Why were so many hurt?  This occurred because a metro train derailed.  According to initial reports in the media, the train derailed because of an issue with a track switch mechanism that had recently been repaired.  It appears there was a problem with the repair work that was done and it can be assumed that the supervision or inspection of the work wasn’t adequate since the problem wasn’t discovered prior to the accident.

A second impact to the safety goal is that it was particularly difficult to quickly access and treat the injured passengers after the accident.  The derailment occurred at the deepest metro station on the Moscow subway, about 275 feet underground.  Rescue workers had to climb down steps to reach injured passengers and had to carry many up to the surface.

After a Cause Map is completed, the final step is to use it to develop solutions that can be implemented to reduce the risk of a similar accident occurring.  In this example, there may be changes needed to how track work is managed.  At a minimum, a careful look into how repair work is inspected prior to a track being put back into service seems warranted after this accident.

Root Cause Analysis - Incident Investigation

DELAY OF RECALL REPAIRS FIRES UP NHTSA

By ThinkReliability Staff

On June 18, 2013, the manufacturer of Jeep Grand Cherokee and Liberty sport-utility vehicles (SUVs) recalled 1.56 million vehicles due to a risk of fuel tank fires during rear-end collisions. At the time of the recall, the National Highway Traffic Safety Administration (NHTSA) linked 51 deaths to the fuel tank fires. Although a fix was accepted in January, parts won’t be available to owners until August.

The NHTSA is concerned about this delay. Says O. Kevin Vincent, NHTSA Chief Counsel, “For many owners, a recall remedy deferred by parts availability easily becomes a defect remedy denied. Moreover, additional delays in implementing this recall with inure to Chrysler’s benefit at the expense of vehicle owner safety.”

Even without full information, a Cause Map can begin to develop the cause-and-effect relationships that led to an issue. As more information is provided, more detail can be added to the Cause Map.

The analysis begins by determining the impacts to the organization’s goals. In this case, the safety goal is impacted by the 51 deaths that were determined to have resulted from gasoline fires as a result of the recall issue as well as 4 additional deaths that have occurred since the recall, according to the executive director of watchdog group Center for Auto Safety. The delay in the repairs for the recall issue can also be considered an impact to the customer service and production goals.

Beginning with one of the impacts to the goals, asking “why” questions builds the Cause Map, a visual root cause analysis. Beginning with the deaths that have occurred as a result of the recall issue since the recall took place, asking “why” questions helps determine that the deaths resulted from the issue at the heart of the recall (the increased risk for gasoline fires) and the delay in repairs from the recall. (Had the repairs been implemented more quickly, the number of deaths as a result of the issue may have been reduced.)

The increased risk of gasoline fires occurs from an increased risk of fuel tank rupture in the event of a rear-end collision because the fuel tank, in an unusual design, is located behind the rear-most axle, which provides inadequate protection. The fix for the recall issue is to add a trailer hitch, which provides an additional distance between another vehicle and the fuel tank in a rear-end collision (but it should be noted will protect only against “lower to medium-speed rear-end crashes”).

Although the addition of trailer hitches was recommended by the manufacturer at the time of the recall, a supplier was not selected until December. The manufacturer has stated that it was finding new suppliers to deal with the higher-than-normal demand for these parts. It’s also possible that the manufacturer was waiting for the NHTSA to approve the fix, which occurred in January. The NHTSA was doing additional testing to ensure that the fix would be effective. After the supplier was selected, it took nearly two months for a purchase order to be issued and five months for production to begin. The reasons for this part of the delay are unknown, and are expected to be provided to the NHTSA near-term.

The delay starting production is one thing; another concern is the amount of time it will take before enough parts are available. The supplier originally selected could manufacture 1,323 Liberty trailer hitches and 882 Grand Cherokee trailer hitches a day, meaning that if all 1.56 million vehicle owners participated in the recall, it would take 4.7 years to produce enough trailer hitches. Currently, legal requirements are only that manufacturers are required to make repairs in a “reasonable time”, although most manufacturers begin repairs within about 60 days of notifying the NHTSA. This case may force the NHTSA to define what a “reasonable time” actually is.

The latest update from Chrysler is that the trailer hitch supplier has increased production capacity and will be able to meet the demand by March of 2015. Chrysler also said that the NHTSA over-estimated the number of hitches required for the recall because the calculations didn’t account for vehicles that are no longer in use or those already equipped with hitches.

To view a timeline, Outline and Cause Map of this issue, please click “Download PDF” above. Or, click here to learn more.

 

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Root Cause Analysis - Incident Investigation

The Controversy Over the 2010 World Cup Ball

By Kim Smiley

Unlike other sports where the balls remain relatively constant, a new soccer ball is typically unveiled for the World Cup every 4 years.  The changes made to the balls aren’t just cosmetic; the behavior of the soccer ball can vary between designs.  One of the most controversial designs in recent memory was the Janulani, the official ball of the 2010 World Cup that was widely criticized and dubbed “the beach ball”.

The issues surrounding the Janulani soccer ball can be analyzed by building a Cause Map, a visual root cause analysis.  To build a Cause Map, “why” questions are asked to determine what factors contributed to an issue and answers are visually laid out to show the cause-and-effect relationships. To view a Cause Map of this issue, click on “Download PDF”.

So why was the 2010 World Cup ball the focus of so many complaints? Players felt that the ball was unpredictable and behaved differently than previous ball designs.  Scientists studied the Janulani ball and determined that it was less aerodynamically stable, particularly at the speeds typical for a professional free kick, which made the goalie’s job significantly harder and tempers flare.  The Janulani ball was a fundamentally different design: it had fewer panels (8 instead of the traditional 32), a smoother surface and internal stitches.  The ball was basically so smooth it changed how air flowed around it, including the speed where the transition between smooth and turbulent flow occurred.  The placement of the seams was also significantly different and not as balanced so that the ball moved erratically at times.  One can assume that the testing program for the new soccer ball design was inadequate since the changes in flight path patterns were not intentional, so that is another cause that needs to be considered.

It’s also worth noting that the fact that a new soccer ball design was used for the 2010 World Cup is a cause of the problem.  Few other sports have equipment that is changed so frequently and/or debut new equipment at major international events. So why is there a new ball for every World Cup?  Money certainly plays a role since there is a huge demand for World Cup merchandise and a new ball means a new product to sell.  The restrictions governing soccer ball design are also vague – for example, the number of panels are not specified – which allows plenty of wiggle room for innovation.

The problems with the 2010 World Cup ball seem to have been fixed and the 2014 World Cup ball, the Brazuca, doesn’t seem to be generating close to the amount of negative press.  In order to smooth out the flight pattern, this design is about a half-ounce heavier, has a slightly rougher surface and deeper seams.  There has been some speculation that the fast flying Brazuca is responsible for the high number of goals scored this World Cup, but the ball appears to fly predictably – if fast. If you want a stylish new Brazuca official match ball of your own, they are selling for $160 each.

If you are still feeling blue that the US is out the World Cup, try searching #ThingsTimHowardCouldSave.  It should cheer you up a bit.

Root Cause Analysis - Incident Investigation

Extensive Fire on USS George Washington Placed Crew at Risk

By ThinkReliability Staff

When fire broke out in 2008 on aircraft carrier USS George Washington in an unmanned space that was being used to improperly store flammable materials, it took more than 8 hours to find the source of, and extinguish, the fire. In the Navy’s investigation report, Admiral Robert F. Willard, commander of the US Pacific Fleet, stated “It is apparent from this extensive study that there were numerous processes and procedures related to fire prevention and readiness and training that were not properly functioning. The extent of damage could have been reduced had numerous longstanding firefighting and firefighting management deficiencies been corrected.”

The processes and procedures that were implicated in the investigation of the fire can be examined in a Cause Map, or a visual root cause analysis. This process begins by identifying the goals impacted. In this case, the primary goal impacted was the safety goal. Thirty-seven sailors were injured; one was seriously burned. There were no fatalities. In addition, the damage to the ship was estimated at $70 million and left the ship unusable for 3 months.

Beginning with the impacted safety goal, asking ‘Why’ questions allows us to develop the cause-and-effect relationships that led to those impacted goals. In this case, the injuries to sailors resulted from the extensive fire aboard ship. In addition, some of the affected sailors (including the sailor who was seriously burned) did not have adequate protective clothing. Specifically, liners worn underneath firefighting gear were not available in one repair locker because they were being laundered. Both the fire and the inadequate protective gear were causally related to the injuries so they are both included on the Cause Map and joined with ‘and’.

Asking additional ‘why’ questions adds more detail to the Cause Map. When investigating a fire, it’s important to include the factors that resulted in the initiation of the fire (heat, fuel and oxygen) as well as those that allowed the fire to spread. In this case, the ignition (or heat) source was believed to be a cigarette butt. On-scene evidence showed that smoking was occurring in the area, against regulation. The ship was found to have inadequate training regarding the smoking policy and inadequate control over the locations where smoking was occurring, because regular zone inspections were not being held.

The initial fuel source was determined to be refrigerant oil and other flammable materials improperly stored in an unmanned space where the fire began. The oil was not turned in as required by procedure over a concern about the difficulty of retrieving it. Because the oil was never entered into the inventory control system, the storage discrepancy was not noted. The unmanned space in which it was stored was not inspected. Unmanned spaces were not included in zone inspections and the area had not been designed as a tank or void to be identified in the void and tank inspection.

Once a fire breaks out, the speed in which the source is found and extinguished has the most impact on the safety of personnel. In this case, the source of the fire was not found for eight hours.   Not only did the fire begin in an unmanned area, the drawings showing the layout of the ship were inaccurate, because the ship was in the midst of alterations.

Developing the causes the resulted in the impacted goals allows for identification of all the processes and procedures that need to be re-examined to reduce risk of recurrence. In this case, the report identified multiple processes and procedures that were re-evaluated in the wake of the disaster, including those for hazardous material storage, training, inspection and firefighting.

To learn more, click here to read the Navy investigation report. To view a one-page overview of the Outline and Cause Map, please click on “Download PDF” above.