Monthly Archives: February 2016

Root Cause Analysis - Incident Investigation

Avoiding Procedure Horrors in Your Little Shop

By ThinkReliability Staff

Are you singing “Suddenly Seymour”, yet?  In this blog, we take a look at the ever-so-interesting example of a Venus Flytrap.  These fascinating creatures have captured imaginations and inspired many science fiction books, movies and even a musical (Little Shop of Horrors).  When thinking about a Venus Flytrap, the “problem” really depends on the point of view   From the point of view of the fly, the problem is getting eaten for lunch.  From the point of view of the Venus Flytrap, the problem is how to catch its lunch.  Since it’s really only a problem for one of the parties, we will  focus on the question of how, and examine the Process Map as a best practice for documenting the how in your shop.

Process Maps are very useful tools.  Converting a written job procedure or word of mouth instructions into a picture or map can illuminate a complicated process and make it seem quite simple.  Asking how something happens, or how something gets done can provide valuable detail that can be useful for anyone attempting that task now and in the future.  The benefit can include preventing or minimizing incidents that often recur from lack of clarity in a procedure.

To start with, a very simple map can be created that shows the process of a Venus Flytrap eating a fly in 4 steps:  The fly lands in the trap, the trap closes, the plant eats the fly, and the trap opens again.  However, this ‘simple’ process is actually extremely complex.  In his recent article titled “Venus Flytraps Are Even Creepier Than We Thought” (The Atlantic, January 21 , 2016), Ed Yong outlines the process and intricacies of how the carnivorous plant works.  When the fly lands on the Flytrap’s bright red and enticing leaves, a complicated process of chemicals, electrical impulses and physics is kicked off… all with very delicate timing.  The Flytrap’s leaves are covered with sensitive hairs.  If the fly touches those hairs more than once in 20 seconds, it begins a process ensuring its own demise.  A well-timed increase in calcium ions and electrical impulses result in water flowing to the Flytrap’s leaves, causing them to change shape, trapping the fly inside.  At this point, the more the fly struggles, the more problems it creates for itself.  Further stimulating these hairs results in more calcium ions and more electrical impulses, this time resulting in the flow of hormones and digestive enzymes.  Over time, the leaves will create a hermetic seal and fill up with liquid, causing the fly to asphyxiate and die.  Next, the pH level of the fluid inside the trap drops to 2, and the digestive process begins in earnest.  Recent research suggests that chemical sensors on the Flytrap’s leaves can detect the level of digestion of the fly, stimulating the release of more digestive enzymes if needed, or causing the trap leaves to open back up.  The Flytrap is then ready to begin the process again.  As Charles Darwin said, “THIS plant, commonly called Venus’ fly-trap, from the rapidity and force of its movements, is one of the most wonderful in the world.”  (1875. Insectivorous Plants)

This Process Map, while detailed, could surely be broken down into further detail by a entomologist who deeply understands the intricate workings of a Venus Flytrap.  Fortunately for a baby Venus Flytrap, this process map is coded directly into its DNA, so it doesn’t have to rely on anything to know what to do.  Unfortunately for us, work-related tasks are rarely so instinctual.  We rely on job procedures, process maps and word of mouth to learn the best, safest way to get the job done. Ensuring consistency with that transfer of information is key to making sure that incidents and problems are avoided.  Problems that result from poorly defined procedures or work processes can go by many names: procedure not followed, human error, etc.  At the end of the day, the roots (pun intended) of many of these problems are poorly articulated or poorly communicated work processes.  The simple tool of a process map can help minimize these problems by making the steps of the process clear and easy to understand.

Root Cause Analysis - Incident Investigation

Investigators Blame “Human Error” for Train Collision

By Kim Smiley

On February 9, 2016, two commuter trains collided head-on in Upper Bavaria, Germany.  Eleven people were killed and dozens were injured.  Investigators are still working to determine exactly what caused the accident and the train dispatcher is currently under investigation for involuntary manslaughter and could face up to five years in prison if convicted.

Although the investigation is still ongoing, some information has been released about what caused the crash.  The two trains collided head-on because they were both traveling on the same track toward each other in opposite directions.  Running two trains on the same track is common practice in rural regions in Germany and these two trains were scheduled to pass each other at a station with a divided track. The drivers of both trains were unaware of the other train.  The accident occurred on a bend in a wooded area so the drivers could not see the other train until it was too late to prevent the collision.

The dispatcher failed to prevent a situation where two trains were running towards each other on the same track or to inform the drivers about the potential for a collision.  Investigators have stated that the dispatcher sent an incorrect signal to one of the trains due to “human error”.  After realizing the mistake – and that a collision was imminent – the dispatcher issued emergency signals to the trains, but they were too late to prevent the accident.

All rail routes in Germany have automatic braking systems that are intended to stop a train before a collision can occur, but initial reports are that the safety system had been manually turned off by the dispatcher.  German media has reported that the system was overridden to allow the eastbound train to pass because it was running late, but this information has not been confirmed.  Black boxes from both trains have been collected and analyzed.  Technical failure of the trains and signaling equipment have been ruled out as potential causes of the accident.

The information that has been released to the media can be used to build an initial Cause Map, a visual root cause analysis, of this issue.  A Cause Map visually lays out the cause-and-effect relationships and aids in understanding the many causes that contributed to an issue. The Cause Map is built by asking “why” questions. A detailed Cause Map can aid in the development of more effective solutions.

One of the general Cause Mapping rules of thumb is that an investigation should not stop at “human error”.  Human error is too general and vague to be helpful in developing effective solutions. It is important to ask “why” the error was made and really work to understand what factors lead to the mistake.  Should the safety system be able to be manually overridden?  Is the training for dispatchers adequate?  Does there need to be a second check on decisions by dispatchers?  Should two trains traveling in opposite directions be sharing tracks?  I don’t know the answers, but these questions should be asked during the investigation.  Charging the dispatcher with involuntary manslaughter may prevent HIM from making the same mistake again, but it won’t necessarily reduce the risk of a similar accident occurring again in the future.  To really reduce risk, investigators need to dig into the details of why the error was made.

Uncategorized

A Lesson in Miscommunication: Valentine’s Day Blues

By Renata Martinez with contributions from the staff of ThinkReliability

I better preface this blog with a few comments….

It’s  not your average blog.  As a facilitator, I deal with a lot of serious problems on a daily basis.  Believe it or not I get these incidents stuck in my head and spend a lot of time thinking how I can better explain some lessons I’ve learned as a facilitator.  The goal of this blog is to offer a little perspective into an incident where “miscommunication” is identified and I wanted to use something you could probably relate to. Have you ever been in an argument with a significant other?  Maybe you didn’t see eye-to-eye on something (a Netflix option perhaps), or someone did something unexpected, or someone said something they didn’t mean (“Feel free to go golfing today; you don’t need to start on that to-do list”).

I also want to preface this blog by stating I am not a relationship counselor and I do not have a perfect relationship because of Cause Mapping.  However, I will say that Cause Mapping has helped me gain an understanding of a whole new perspective – his.

Without further ado, let me set the stage.  I have to take you back a bit.  Let me take you back to my Sophomore year in college. *enters dream state*

Valentine’s Day:  I hate it.  I’ve always thought it was a commercialized endorsement to express love.   The seemingly endless aisles in store after store of red and white hearts, chocolates, cards, teddy bears – gross.  …and then I met my future husband.  I was so head over heels for this guy, you would have thought I was 12 (but I was 20).  So when Valentine’s Day came around our new love I was actually excited.  The thought crept into my mind that I could be wow-ed this time; this could be it, I could learn to love Valentine’s Day.  I had the opportunity to relive every Nicolas Sparks novel ever written.  Expectations were set.

Leading up to the 14th, there was a conversation that took place that would ensure I will always despise the day…. I was asked what I wanted.  My mind quickly played one romantic scene after another but that’s not what came out of my mouth.  Instead I replied, “nothing.”  Well, being the literal person he is, he took this and ran with it – he got me nothing.  I was so disappointed because when I said “nothing”, OF COURSE I DIDN’T MEAN IT.   “Nothing” was a clear translation for: you figure it out, you surprise me with some immaculate plan. I didn’t want to spell out what I wanted; I wanted to be the cool, low maintenance, laid back girlfriend. I don’t think he was too impressed with my “cool, laid back attitude” when I came to the realization that I didn’t get anything for Valentine’s day – the first time I actually wanted something.

So that’s one branch of the Cause Map: why did I not ask for anything on Valentine’s Day?

At this same point of the Cause Map, it splits with an AND statement.  He also had to assume that I meant “nothing” when he asked.  In my mind it’s so obvious…it’s like when I haven’t talked or looked at you all day and when you ask “What’s wrong?” and I say “Nothing.”  I don’t mean it; it’s just an impulse reaction (and admittedly makes understanding me very difficult).  But since this was his first experience with me and this kind of situation, he didn’t think more about it.  He didn’t realize that I may actually want something.

I know this is a basic example of understanding both perspectives but it comes up a lot on investigations.  Understanding how people both give and interpret instructions/ directions is very important with regards to understanding solutions.  For instance, I will never say that I want “nothing” for a holiday ever again.  My new minimum “requirement” is a card. I really like cards.  And since I’ve got your attention, I’ll give you a little hint about present-giving: the presents should always be wrapped…in gift wrap (the bag from the store does not count).

Looking at solutions for him: he no longer takes the answer “nothing” literally.  Based on this experience, he now understands that I may not mean it.  So, the solutions identified will help him, but if we were looking at a different employee (or boyfriend in this example) – how do we ensure it doesn’t happen to them? This is where we need to consider others who may learn from this (not just those directly affected in this incident).  And this is why sharing lessons learned is so important.

By identifying both perspectives on the Cause Map, we can learn a lot about why an incident occurred (and what had to happen).  This yields more effective solutions that will prevent reoccurrence.  …after all: happy wife, happy life . . . right?!

To view both perspectives on a Cause Map, click on “Download PDF” above.

 

Root Cause Analysis - Incident Investigation

Failure of the Nipigon River Bridge

By Kim Smiley

On the afternoon of January 10, 2016, the deck of the Nipigon River Bridge in Ontario unexpectedly shifted up about 2 feet, closing the bridge to all vehicle traffic for about a day.  After an inspection by government officials and the addition of 100 large cement blocks to lower the bridge deck, one lane was reopened to traffic, with the exception of oversized trucks. Heavier trucks are required to detour around the bridge with the main alternative route requiring crossing into the United States.  This failure is still being investigated and it isn’t known yet when it will be safe to open all lanes on the bridge.

More information is needed to understand all the details that led to this failure, but an initial Cause Map, a visual root cause analysis, can be built to illustrate what is currently known. The first step in the Cause Mapping process is to fill in the Outline to document the basic background information (the what, when and where) and the impacts to the organization’s goals resulting from the issue.  For this example, the bridge was damaged and significant resources will be needed to investigate the failure and repair the bridge.  The closure of the bridge, and subsequently having only a single open lane, is also having a sizable impact on transportation of both people and goods in the area.  It is estimated that about $100 million worth of goods are moved over the bridge daily and there are limited alternative routes.

Once the Outline is completed, the Cause Map is built by asking “why” questions and visually laying out the cause-and-effect relationships.  Why did the deck of the bridge shift up?  Investigators still don’t have the whole answer. The Nipigon River Bridge is a cable stayed bridge and bolts holding the bridge cables failed, resulting in the deck of the bridge being pulled up at an expansion joint.  Two independent testing facilities, National Research Council of Canada in Ottawa and Surface Science Western at Western University, are conducting tests to determine the cause of the bolt failures, but no information has been released at this time.

The Nipigon River Bridge is a new bridge that has only been open since November 29, 2015. Some hard questions about the adequacy of the bridge design have been asked because the failure occurred so soon after construction.  Officials have stated that the bridge design meets all applicable standards, but investigators will review the design and structure during the investigation to ensure it is safe.  Ontario winters can be harsh and investigators are going to look into whether cold temperatures and/or wind played a role in the failure.  Eyewitnesses have reported a large gust of wind just prior to the bolt failure.  Investigators will determine what role the wind played.

The Cause Map can easily be expanded to incorporate new information as it becomes available. Once the Cause Map is completed, the final step in the Cause Mapping process is to develop solutions to prevent a similar problem from recurring.  In this example, adding the concrete blocks as counter weights allowed one lane of the bridge to be opened in the short term, but clearly a longer-term solution will be needed to repair the bridge and ensure a similar failure does not occur again.