Celebrating with a bit of bubbly? Read this first . . .

By Angela Griffith

What better day than New Year’s Eve to pop open a bottle of champagne (or its non-French sibling, sparkling wine)? Great thought, but turns out there’s a right way to open a bottle of bubbly, and “pop” has nothing to do with it.

Your initial thought may be who cares? What possible difference could it make how I open a bottle? Well, assuming your goal is to celebrate an enjoyable evening with friends, family, or maybe a date, using an improper opening procedure could impact the safety goal, by injuring yourself or others. It can also affect your reputation by failing to impress those with whom you’ve chosen to celebrate (as well as anyone else in the vicinity). The lost champagne is an impact to the property goal, and the potential for clean-up impacts the labor goal (and is clearly not what you want to be spending your New Year’s Eve doing).

A study claims that 900,000 injuries per year result from champagne. Injuries typically result from corks hitting faces, especially eyes. The pressure inside a bottle of champagne can be as high as 90 pounds per square inch, resulting in a cork traveling at speeds of up to 50 miles an hour. Injuries resulting from slips on spilled champagne also fall into this category.

Both spills and flying corks can be prevented by using a proper procedure to open a bottle of champagne. The preparation starts far before the party does. The first step is to ensure that the champagne is cooled properly. This is not only for taste, but also for safety. Another study found that cooling the bottle to 39 degrees F (4 degrees C) reduces the speed at which the cork leaves the bottle. (The cork travels only 3/4 of the speed of that from a room temperature, or 64 degrees F, bottle.)

Once you’re ready to serve the champagne, grab the bottle, glasses, and a kitchen towel. Check to see if there’s a tab on the foil covering the neck. If not, you’ll also need a knife. (One thing you won’t need? A corkscrew.) Remove the foil from the neck, by pulling the tab if one is present or by cutting with a knife, and then peeling it off. From this point until you start pouring, keep the bottle pointed at a 45 degree angle, and away from people, breakable objects, walls and ceilings. Untwist the wire tab, or key, and remove the wire cage, and hold your thumb over the cork. Cover the cork and neck of the bottle with the kitchen towel, and grab both the towel and cork with one hand. With the other hand, gently and slowly twist the bottle until the cork slides out. (This will be not with a pop, but more of a whimper.) Do not shake the bottle!

Hold champagne flutes at an angle and pour champagne in on the side to preserve the bubbles. Repeat as necessary. If you’ll need to leave the location at which you are drinking, please do it as a passenger, or wait until you’ve sobered up. For an average person, that means waiting about an hour for every 5 ounces of wine/ champagne consumed. (The drink size of other kinds of alcohol is defined differently, and your weight will impact the time it takes for alcohol to leave your system.)

If you or someone else forgets these rules and ends up getting hit in or near the eye with a champagne cork, take a trip to the ophthalmologist right away. (Because it’s New Year’s Eve, you may have to hit the emergency room first.) Says ophthalmologist Andrew Iwach, MD, “The good news is that as long as we can see these patients in a timely fashion, then there’s so many things we can do to help these patients preserve their vision.”

To view a visual diagram of the proper champagne-opening procedure, click on “Download PDF” above.

The year Christmas almost wasn’t

By Kim Smiley

The movie Elf, starring Will Ferrell as Buddy the elf, tells the story of a Christmas that nearly disappointed children worldwide.  On Christmas Eve night, as Santa made his magical trip to deliver his bag of Christmas gifts, his sleigh crashed in Central Park in New York City.  Only quick thinking by Buddy and his friends got Santa airborne again and saved the holiday.

A Cause Map, a visual root cause analysis, can be built to analyze the crash of Santa’s sleigh.  A Cause Map is built by visually laying out all the cause-and-effect relationships that contributed to the issue.  The first step in the Cause Mapping process is to fill in an outline with the basic background information as well as impacts to the goal.  Nearly every problem impacts more than one goal and listing all the impacts helps fully understand the scope of the issue.

In this example, there is potential risk of damage to the sleigh and injury to the big guy himself which would be an impact to the equipment goal and safety goal respectively.  There was a delay in the present delivery schedule while Santa’s sleigh was on the ground, but the biggest concern was the impact to the customer service goal because millions of children had the potential to wake up to a Christmas morning without gifts, certainly something Santa and his elves desperately wanted to avoid.   Once the Outline is completed, the Cause Map itself is built by starting at one impacted goal and asking “why” questions.

So why did Santa’s sleigh crash into Central Park?  Santa’s sleigh crashed because it was high above the ground and it lost propulsion.  Flying is the sleigh’s typical mode of operation because Santa needs a speedy, magical mode of transportation to do his job.  The sleigh lost propulsion because both the primary and secondary propulsion systems failed.

Originally, Santa’s sleigh was powered purely by Christmas cheer, but levels of Christmas cheer have been steadily declining in modern times and a secondary system, a Kringle 3000, 500 Reindeer-Power jet engine, had to be added in the 1960s to keep the sleigh flying.  On the Christmas in question, the level of Christmas cheer hit an all-time low and the strain on the jet engine mount was too great and it broke off.  Without the jet engine, Santa’s sleigh crashed. Luckily, Buddy had told his friends that “the best way to spread Christmas cheer is singing loud for all to hear” and they were able to inspire enough folks to sing along with carols that Santa’s sleigh flew back into action and the children got their presents.

One would hope that the design of the jet engine was improved after this accident, but just to be safe and ensure that there are no sleigh crashes this year, make sure you sing plenty of Christmas carols loudly for all your friends and families to hear!  And if you are concerned about Santa’s progress and want assurances that all is well, you can monitor his progress around the world at the NORAD Santa tracker.

Newly Commissioned USS Milwaukee Breaks Down at Sea

By Angela Griffith

On December 11, 2015, just 20 days after commissioning, the USS Milwaukee completely lost propulsion and had to be towed back to port. This obviously brought up major concerns about the reliability of the ship. Said Senator John McCain (R-Arizona), head of Senate’s Armed Services Committee, “Reporting of a complete loss of propulsion on USS Milwaukee (LCS 5) is deeply alarming, particularly given this ship was commissioned just 20 days ago. U.S. Navy ships are built with redundant systems to enable continued operation in the event of an engineering casualty, which makes this incident very concerning. I expect the Navy to conduct a thorough investigation into the root causes of this failure, hold individuals accountable as appropriate, and keep the Senate Armed Services Committee informed.”

While very little data has been released, we can begin an investigation with the information that is known. The first step of a problem investigation is to define the problem. The “what, when and where” are captured in a problem outline, along with the impacts to the organization’s goals. In this case, the mission goal is impacted due to the complete loss of propulsion of the ship. The schedule/production goal is impacted by the time the ship will spend in the shipyard receiving repairs. (The magnitude and cost of the repairs has not yet been determined.) The property/equipment goal is impacted because metal filings were found throughout both the port and starboard engine systems. Lastly, the labor and time goal is impacted by the need for an investigation and repairs.

The next step of a problem investigation is the analysis. We will perform a visual root cause analysis, or Cause Map. The Cause Map begins with an impacted goal and asking “why” questions to diagram the cause-and-effect relationships that led to the incident. In this case the complete loss of propulsion was caused by the loss of use of the port shaft AND the loss of use of the starboard shaft. The ship has two separate propulsion systems, so in order for the ship to completely lose propulsion, the use of both shafts had to be lost. Because both causes were required, they are joined with an “AND”.

We continue the analysis by continuing to ask “why” questions of each branch. The loss of use of the port shaft occurred when it was locked as a precaution because of an alarm (the exact nature of the alarm was not released). Metal filings were found in the lube oil filter by engineers, though the cause is not known. We will end this line of questioning with a “?” for now, but determining how the metal filings got into the propulsion system will be a primary focus of the investigation. The loss of use of the starboard shaft occurred due to lost lube oil pressure in the combining gear. Metal filings were also found in the starboard lube oil filter. Again, it’s not clear how they got there, but it will be important to determine how the lube oil system of a basically brand new ship was able to obtain a level of contamination that necessitated full system shutdown.

While metal filings in the lube oil system is not a class-wide issue, it’s not the first time this class of ship has had problems. The USS Independence and USS Freedom, the first two ships of the class, suffered galvanic corrosion which caused a crack in the Freedom’s hull. The Freedom also suffered issues with its ship service diesel engines, a corroded cable, and a faulty air compressor.

Once all the causes of the breakdown are determined, engineers will have to determine solutions that will allow the ship to return to full capacity. Additionally, because of the number of problems with the class, the investigation will need to take a good look at the class design and manufacturing practices to see if there are issues that could impact the rest of the class going forward.

To view a one-page downloadable PDF with the beginning investigation, including the problem outline, analysis, and timeline, click “Download PDF” above.

Component Failure & Crew Response, Not Weather, Brought Down AirAsia Flight QZ8501

By Angela Griffith

Immediately following the December 28, 2014 crash of AirAsia flight QZ8501, severe weather in the area was believed to have been the cause of the loss of control of the plane. (See our previous blog on the crash.) However, recovery of the “black box” and a subsequent investigation determined that it was a component failure and the crew’s response to the upset condition that resulted in the crash and that weather was not responsible. This is an example of the importance of gathering evidence to support conclusions within an investigation.

Says Richard Quest, CNN’s aviation correspondent, “It’s a series of technical failures, but it’s the pilot response that leads to the plane crashing.” Because, as in common in these investigations, there is a combination of causes that resulted in the crash, it can help to lay out the cause-and-effect relationships. We will do this in a Cause Map, a visual form of root cause analysis. The Cause Map is built by beginning with an impact to the goals, such as the safety goal, and asking why questions.

The 162 deaths (all on board) resulted from the plane’s rapid (20,000 feet per minute) plunge into the sea. According to the investigation, the crash resulted from an upset/ stall condition AND the crew’s inability to recover from that condition. Because both of these causes contributed to the crash, they are both connected to the effect (crash) and separated with an “AND”.

More detail can be added to each “leg” of the Cause Map by continuing to ask “why” questions. The prolonged stall/ upset condition resulted from the aircraft being pushed beyond its limits. (It climbed 5,400 feet in about 30 seconds.) This occurred because of manual handling and because of the failure of the rudder travel limiter system, which is designed to restrict rudder movement to a safe range. The system failed due to a loss of electrical continuity from a cracked solder joint on a circuit board. Although maintenance records showed 23 complaints with the system in the year prior to the crash, it was not repaired. A former pilot and member of the investigation team stated it was considered “minor damage” and was “not a concern”.

The plane was being manually controlled because the autopilot and autothrust were disengaged. These systems were disengaged when a circuit breaker was reset (removed and replaced) to attempt to reset the system after a computer system failure (indicated by four alarms that sounded in the cockpit). While this is sometimes done on the ground, it shouldn’t be done in the air because it disengages the autopilot and autothrust systems. However, the crew had inadequate upset recovery training. According to the manual from the manufacturer the aircraft is designed to prevent it from becoming upset and therefore training is not necessary. The decision to manually place the plane in a steep climb is believed to have been an attempt to get out of the poor weather. Just prior to the crash, the less experienced co-pilot was at the controls.

The lack of crew training on upset conditions is also believed to have caused the crash. In addition, for at least some time prior to the crash, the pilot and co-pilot were working against each other by pushing their control sticks in opposite directions. The pilot was heard on the voice recorder calling for them to “pull down”, although “pulling” is used to bring the plane up.

The only recommendation that has so far been released is for commercial pilots to undergo flight simulator training for this type of emergency situation. AirAsia has already done so. The company, as well as the aviation industry as a whole, will hopefully look at the conclusions of the investigation report with a very critical eye towards improving safety.

Why New Homes Burn Faster

By Kim Smiley

Screen Shot 2015-12-04 at 11.50.42 AMResearch has shown that new homes burn up to eight times faster than older homes.  What this means is that people have less time to get out of a house when a fire starts – a lot less time.  People living in older homes with traditional furnishings were estimated to have about 17 minutes to safely evacuate a home, but the time decreases to about three minutes in a home built with modern materials and furnished with newer, synthetic furniture.

Modern manufactured wood building materials have a lot of advantages. They are lighter, stronger and cheaper than using traditional wood materials, but these characteristics also mean they burn a lot faster.  Additionally, modern homes typically contain more potential fuel for fires. Many modern furnishings are manufactured using synthetics that contain hydrocarbons, which are a flammable petroleum product.  Furnishings manufactured with synthetic products will burn faster and hotter than traditional furnishings built using wood, cotton and down.  Most modern homes also just simply have more stuff in them that is potential fuel.

Other factors can also make modern homes more dangerous when a fire occurs. Many modern homes are open concept designs as opposed to more compartmentalized traditional designs.  Open spaces in a home can provide more oxygen for a fire to quickly grow.  Additionally, modern energy-efficient windows can help trap heat in a home when a fire starts and can lead to a fire spreading more rapidly. Changes in the way we live and build homes and furnishings have all contributed to modern homes building significantly faster, a potential danger that people need to be aware of so that they can work to keep themselves and their children safe.

The best way to protect yourself and your family is to prevent a fire from occurring in the first place.  Never leave candles burning unattended. Keep all potentially flammable items away from fireplaces and heaters. Don’t leave things on the stove unattended. During the holidays, make sure to keep Christmas trees well watered and away from heat sources and ensure candles are a safe distance from any potentially flammable objects.   These and other basic common sense steps really do prevent fires from occurring.

Of course there is no way to guarantee that a fire will never occur so every house needs working smoke detectors.  It is recommended that they are checked monthly to verify they are functional and that the batteries are changed regularly.  Most fatalities associated with home fires are in homes without working smoke detectors so it really is worth the time and effort to ensure they are kept in good working order.

To view a Cause Map, a visual root cause analysis of this issue, click on “Download PDF” above.