Monthly Archives: April 2015

Root Cause Analysis - Incident Investigation

Earthquake Hits Nepal

By Kim Smiley

As anyone paying any attention to the news knows, a magnitude 7.8 earthquake hit Nepal on April 25, 2015.   The same forces that created the Himalayan Mountains are still at work in the region as the Indo-Australian Plate slowly slides under the Eurasian Plate and experts have long warned about the potential for an earthquake in this location.

At least 4,600 people were killed as a result of the earthquake and the United Nations has stated that 8 million people have been affected.  Many people impacted by the disaster lack adequate water and food and are living in temporary shelters without sanitation facilities.  Beyond the sheer scope of the natural disaster, providing emergency assistance has also been difficult because some of the affected villages are in remote locations that are challenging to access and many roads were damaged by the earthquake.  The long-term economic impacts are also predicted to be large because of the significant damage to infrastructure and the fact that local economies relay heavily on tourism.

A Cause Map, a visual root cause analysis, can be built to help understand this disaster better. A Cause Map lays out the cause-and-effect relationships in an intuitive format by asking “why” questions.  In this tragic example, asking why so many fatalities occurred shows that the majority of deaths were caused by collapsing buildings.  Many buildings in the impacted area were unreinforced masonry structures that couldn’t withstand the force of the earthquake.  These buildings are cheaper and quicker to build than more modern construction that would meet building codes designed to survive an earthquake.

Civil unrest in the region has resulted in rapid urbanization and a large demand for housing as people moved into cities. Rapid and relatively unregulated urbanization in a country with one of the lowest per capita incomes in the world proved to be a deadly combination in a region prone to earthquakes. Historically a major earthquake has struck this region about every 75 years and this one had long been predicted.  Says Susan Hough, a geologist with the U.S. Geological Survey, “It was clearly a disaster in the making that was getting worse faster than anyone was able to make it better. You’re up against a Himalayan-scale problem with Third World resources.”

Every disaster and the emergency response to it should be studied to see if there are any lessons learned that can be used to save lives and minimize damage in the future. There is clearly no “solution” that can prevent an earthquake, but even when dealing with a natural disaster there are ways the impact of a disaster could be mitigated.  The possible solutions may not be cheap or easy, but it is important to remember that it is possible. You can’t stop the earthquake, but you can work to build stronger buildings.

Root Cause Analysis - Incident Investigation

Concrete slab smashes truck killing 3

By Kim Smiley

On April 13, 2015, a large section of a concrete barrier fell from an overpass onto a truck in Bonney Lake, Washington. A couple and their baby were in the vehicle and were all killed instantly. Investigators are working to determine what caused this accident and to determine why the road under the overpass remained open to traffic while construction was being done on the overpass.

A Cause Map, a visual method of root causes analysis, can be built to help understand this accident. More information is still needed to understand the details of the accident, but an initial Cause Map can be created now to capture what is known and it can be easily expanded to include additional information as it becomes available. A Cause Map is created by asking “why” questions and visually laying out the answers to show the cause-and-effect relationships. (Click here to learn more about basics of Cause Mapping.)

In this accident, three people were killed because the vehicle they were riding in was smashed by a large slab of concrete. The vehicle was hit by the concrete slab because it was accidently dropped and the truck was under the overpass at the time it fell because the road was open to traffic. (When two causes are both needed to produce and effect, the causes are listed on vertically on the Cause Map and separated by and “and”.) The road would typically have been closed to traffic while heavy work was performed on the overpass, but the work plan for the construction project did not indicate that any heavy work would be performed on the day of the accident.   At some point the actual work schedule must have deviated from the planned schedule, but no change was made in plan for managing traffic resulting in traffic traveling under the overpass while potentially dangerous construction was performed.

Investigators are still working to understand exactly why the concrete slab fell, but early indication is that temporary metal bracing that was supporting the concrete may have failed due to buckling. The concrete barrier on the overpass were being cut into pieces at the time of the accident so that they could be removed as part of a $1.7 million construction project to improve pedestrian access which included adding sidewalks and lights.

Once the details of what causes this tragic accident are better understood, solutions can be developed and implemented that will help reduce the risk of something like this happening again. To view a high level Cause Map of this accident, click on “Download PDF” above.

You can also read a previous blog “Girder Fell on Car, Killing 3” to learn more about a similar accident that occurred in 2004.

Root Cause Analysis - Incident Investigation

Distraction Related Accidents: Eyes on Road, Hands on Wheel, AND Mind on Task

By  Sarah Wrenn

Admit it – you’ve checked your phone while driving.  We’ve likely all been guilty of it at some point.  And despite knowing that we’re not supposed to do it – it’s against the law in most states and we understand that the distraction increases our risk of having an accident – we still do it.  Why?

On March 31, 2015, the National Transportation Safety Board (NTSB) held its first roundtable discussion on distractions within the transportation industry.  In 2015, the NTSB added “Disconnect from Deadly Distractions” to its “Most Wanted List of Transportation Safety Improvements for 2015.”  This list represents the NTSB’s priorities to increase awareness and support for key issues related to transportation safety.  Other critical topics include “Make Mass Transit Safer” and “Require Medical Fitness for Duty.”

Representatives from all modes of transportation, technology, law enforcement, insurance, researchers, advocates, and educators came together for discussion related to distractions facing vehicle operators.

“New technologies are connecting us as never before – to information, to entertainment, and to each other,” said NTSB Member Robert Sumwalt. “But when those technologies compete for our attention while we’re behind the wheel of a car or at the controls of other vehicles, the results can be deadly.”

Digging into the causes

So let’s take a look at some of the causes related to an accident where the operator is distracted.  In addition to the accident occurring because of the distraction, the level of driver expertise is also a factor.  A large effort has been made to raise awareness and provide education to teenage drivers.  This is in part because, as novice drivers, they have a more limited exposure to driving situations and may not have the ability to react as a more skilled driver.

Operators become distracted

We also want to understand the causes that led to the operator being distracted.  There is a distraction type (or mode) that was introduced, the duration of the distraction, and the individual’s inability to ignore the distraction that result in the operator distraction.  While the type of distraction plays a large role in taking the operator’s eyes off the road, hands off the wheel or mind off the task, the duration of the distraction also is a key factor.  For example, while one’s eyes remain on the road during a phone call, the duration of that call disengages the brain from the task for more time than the act of dialing the phone.  This is not to say that one of these actions is more or less impactful; it is important to note that they both play a role in distracting the individual.

It’s not just the text that is distracting

There are three primary forms of distractions – Visual (taking eyes off of the road), Manual (taking hands off of the wheel), and Cognitive (taking mind off of the task).  Visual and manual types of distractions are very easy to define and generally recognized as risky behaviors while operating a vehicle.  Cognitive distractions are less tangible and therefore more difficult to define.  Research and studies generally define cognitive distractions as when the individual’s attention is divided between two or more tasks.  While technology and activities such as texting or talking on the phone are typically identified as the primary forms of distraction, it is interesting to note that cognitive distractions such as allowing your mind to wander while operating a vehicle can be just as risky.  The AAA Foundation released a 2013 study “Measuring Cognitive Distraction in the Automobile.”  The study rates various tasks such as using a hands-free cell phone and listening to the radio according to the amount of cognitive workload imposed upon an operator.  The study concludes that “while some tasks, like listening to the radio, are not very distracting, others – such as maintaining phone conversations and interacting with speech-to-text systems – place a high cognitive demand on drivers and degrade performance and brain activity necessary for safe driving.”

The forum discussed the concept that ability to multi-task is actually a myth, with evidence and data to conclude that for certain types of activities multi-tasking is not only difficult, but impossible.  For example, tasks such as navigation and speech require the use of the same circuits within the brain.  As such, the brain cannot do both tasks at once.  Instead, the brain is switching between these tasks, resulting in a reduction of focus on the primary task (driving) while attempting to perform a secondary task (speaking).  Therefore, attempting to multi-task introduces a cognitive distraction that increases the risk of unsafe driving.

Just ignore it

Why don’t we just ignore the temptation to become distracted?

Our brains function by releasing serotonin and dopamine when an action occurs that makes us feel good.  Dr. Paul Atchley of the University of Kansas stated: “There is nothing more interesting to the human brain than other people.  I don’t care how you design your vehicle or your roadways, if you have technologies in the vehicle that allow you to be social, your brain will not be able to ignore them.  There are only two things we love, serotonin and dopamine.  The two reward chemicals that come along with all those other things that make us feel good.  There is really nothing more rewarding to us than the opportunity to talk to someone else.”

Surveys performed by various organizations have revealed a large percentage of people (sometimes 3 out of 4) that will admit to being distracted while driving.  Meanwhile, a staggering percent (upwards of 90%) will rationalize the behavior which is a sign of addiction.

Finally, the level of brain development controls our ability to respond to distractions.  For example, a teenager has a less developed fontal cortex than an adult which means, as Dr. David Strayer of the University of Utah explains: “Teens’ frontal cortex, the parts of the brain that do decision-making in terms of multitasking, are underdeveloped.”  Much of the focus on distracted driving is focused on teens and this is justified as their brain development is not yet complete.  It is, however, important to note that this is not just an issue for teens who can’t be separated from their phones or seniors who don’t understand them; this is an issue that crosses all demographics.  Level of brain development is just one factor.

So what can we do?

At the end of the day, we want to identify solutions that are going to effectively reduce the risk of having accidents related to distractions from occurring.  While there will always be some risk, it is key to take a comprehensive approach to education, technology, and policy.  Programs like EndDD.org and stopdistractions.org are focused on bringing awareness, education, and training to youth and adults about the risks of operating vehicles while distracted.  Technology can also be used in a variety of ways to reduce the risk of these types of accidents.  Sensors can be built into vehicles to identify distractions and provide alerts to drivers or apps can be used to disable functions of technology so the receipt of calls and texts are delayed.  Finally, establishing policies and laws that are realistic and enforceable is important so that individuals are held accountable for risky behaviors before an accident occurs.  No one single solution is going to reach everyone and no one single solution is going to eliminate the risk of deadly accidents.  Each one of these solutions has limitations, but they also have advantages.  With a balanced approach to raise awareness and education, provide resources and tools to drivers, and change the culture of what is acceptable while driving, we can reduce the amount of accidents and save lives.

References:

NTSB Roundtable: Disconnect from Deadly Distractions held March 31, 2015, from 9:00 a.m. – 4:00 p.m.

AAA Foundation: Measuring Cognitive Distraction in the Automobile, June 2013

Uncategorized

Crash of Germanwings flight 95252 Leads to Questions

By ThinkReliability Staff

On March 24, 2015, Germanwings flight 9525 crashed into the French Alps, killing all 150 onboard. Evidence available thus far suggests the copilot deliberately locked the pilot out of the cockpit and intentionally crashed the plane. While evidence collection is ongoing, because of the magnitude of this catastrophe, solutions to prevent similar recurrences are already being discussed and, in some cases, implemented.

What is known about the crash can be captured in a Cause Map, or visual form of root cause analysis. Visually diagramming all the cause-and-effect relationships allows the potential for addressing all related causes, leading to a larger number of potential solutions. The analysis begins by capturing the impacted goals in the problem outline. In this case, the loss of 150 lives (everybody aboard the plane) is an impact to the safety goal and of primary concern in the investigation. Also impacted are the property goal due to the loss of the plane, and the recovery and investigation efforts (which are particularly difficult in this case due to the difficult-to-access location of the crash.)

Asking “Why” questions from the impacted goals develops cause-and-effect relationships. In this case, the deaths resulted from the crash of the plane into the mountains of the French Alps. So far, available information appears to support the theory that the copilot deliberately crashed the plane. Audio recordings of the pilot requesting re-entry into the cockpit, the normal breathing of the co-pilot, and the manual increase of speed of the descent while crash warnings sounded all suggest that the crash was deliberate. Questions have been raised about the co-pilot’s fitness for duty. Some have suggested increased psychological testing for pilots, but the agency Airlines for America says that the current system (at least in the US), is working: “All airlines can and do conduct fitness-for-duty testing on pilots if warranted. As evidenced by our safety record, the U.S. airline industry remains the largest and safest aviation system in the world as a result of the ongoing and strong collaboration among airlines, airline employees, manufacturers and government.”

Some think that technology is the answer. The flight voice recorder captured cockpit alarms indicating an impending crash. But these were simply ignored by the co-pilot. If flight guidance software was able to take over for an incapacitated pilot (or one who deliberately ignores these warnings, disasters like this one could be avoided. Former Department of Transportation Inspector General Mary Schiavo says, “This technology, I believe, would have saved the flight. Not only would it have saved this flight and the Germanwings passengers, it would also save lives in situations where it is not a suicidal, homicidal pilot. It has implications literally for safer flight across the industry.”

Others say cockpit procedures should be able to prevent an issue like this. According to aviation lawyers Brian Alexander & Justin Green, in a blog for CNN, “If Germanwings had implemented a procedure to require a second person in the cockpit at all times – a rule that many other airlines followed – he would not have been able to lock the pilot out.”

After 9/11, cockpit doors were reinforced to prevent any forced entry (according to the Federal Aviation Administration, they should be strong enough to withstand a grenade blast). The doors have 3 settings – unlock, normal, and lock. Under normal settings, the cockpit can be unlocked by crewmembers with a code after a delay. But under the lock setting (to be used, for example, to prevent hijackers who have obtained the crew code from entering the cockpit), no codes will allow access. (The lock setting has to be reset every 5 minutes.) Because of the possibility a rogue crewmember could lock out all other crewmembers, US airlines instituted the rule that there must always be two people in the cockpit. (Of course, if only a three-person crew is present, this can cause other issues, such as when a pilot became locked in the bathroom while the only other two flight crew members onboard were locked in the cockpit, nearly resulting in a terror alert. See our previous blog on this issue.)

James Hall, the former chairman of the National Transportation Safety Board, agrees. He says, “The flight deck is capable of accommodating three pilots and there shouldn’t ever be a situation where there is only one person in the cockpit.” In response, many airlines in Europe and Canada, including Germanwings’ parent company Lufthansa, have since instituted a rule requiring at least two people in the cockpit at all times.   Other changes to increase airline safety may be implemented after more details regarding the crash are discovered.

Root Cause Analysis - Incident Investigation

THE WOEFUL TALE OF JACK & JILL

By Jon Bernardi

There has been a disturbing rise of injuries once thought to have been eradicated. Several federal and state agencies are considering legislation to address the very dangerous injuries from the gathering of liquid di-hydrogen oxide from certain unprotected hills and wells. Once upon time became the last straw, when siblings Jack and Jill fetched the ill-fated pail. Not only were crowns injured, but various homeopathic remedies were implemented with little consequence except to other participants, notably Jill.

What caused this unfortunate turn of events?

That question can be answered by building a Cause Map, a visual root cause analysis.  In the Cause Mapping process, the first step is to fill in an Outline with the background information for an issue as well as how the problem impacts the goals.  In this example, the aforementioned fetching impacts quite a number of goals: Safety as crowns were broken; environmental, the spilled di-hydrogen oxide; regulatory, child corporal punishment and child labor laws; customer service, no di-hydrogen oxide available for multiple purposes; production, the delay of supper; and labor, the time needed for medical attention.

Fortunately no property was lost as the well-made bucket survived intact.  Once we have filled out the Outline, the next step is to ask “why” questions to find the different causes that contributed to the problem being analyzed.

So why were they going up a hill? This presents us with a number of potential paths of exploration as to why the well was at the top of a hill. Even without knowing a detailed answer we know that a potential solution would be to get them hooked up an established di-hydrogen oxide system as soon as possible!

Why was there no protection? Broken crowns are a serious affair. This combined with the potential for other injuries from the fractious “tumbling down” incident leaves us to wonder how the well could be constructed in such a manner.

These are areas for further exploration. Even with the unanswered questions we are still able to propose several solutions to ensure that child labor laws are not ignored, hills are properly protected, and home remedies are carefully considered.

To view an Outline and a high level Cause Map for this issue, click on “Download PDF” above.