By Kim Smiley

On January 26, 2010 just before 2 am, two Metro workers were killed near the Rockville metro station.  They were crushed by a metro utility vehicle while working on the track to install safety equipment.

The utility vehicle is a gas powered truck that is designed to operate on the track when electricity is shut off.  They are called high-rail vehicles and are typically used to carry equipment.  At the time of the accident, the vehicle was placing devices that tell approaching trains that there is a work crew in the area.

Many details of this accident are not available yet, but a preliminary root cause analysis can be started.  The basic information can be documented in an Outline and an initial cause map can be started.  Click on the “Download PDF” button above to see what this would look like.

The men killed and the workers in the vehicle were not part of the same crew and it’s not clear why the driver of the truck wasn’t aware that workers were in the area.  At the time of the accident the vehicle was traveling in reverse, which is a routine mode of operation.

Safety regulations require all vehicle operators to be informed about work crew locations, but it isn’t clear if that is being done effectively.

The National Transportation Safety Board (NTSB) has begun to investigate this incident and more details should be available as their investigation progresses.   The NTSB is currently reviewing employee work history and training and gathering all relevant data such as radio recordings and work procedures.

The DC Metro system has the worst safety record of any metro system in the country.  Five workers have now been killed while on the tracks in the last seven months.  There was also a metro train accident that killed 9 people on June 22, 2009.  To see a cause map of the June accident, click here.

By Kim Smiley

High-speed train service in the Channel Tunnel (connecting Britain, France and Belgium) resumed partially on Tuesday, December 22, 2009 after a complete stoppage that began Friday, December 18th when five trains failed inside the tunnel.

Eurostar, the operator of the train, has stated that the failure of the trains were caused by an electrical failure due to condensation from snow that was able to enter the snow screens protecting the engine and higher temperatures within the tunnel than outside. Unseasonably cold weather was believed to cause finer, lighter snow than usual, which was able to enter the screens.

There was a delay in rescuing the trapped passengers in the tunnel – some of whom were trapped for up to 18 hours. Responsibility for rescue lies with both the train operator and the tunnel operator, and the process for rescue obviously needs to be reviewed by both parties to determine a better course of action the next time a rescue plan is needed. Additionally, the train operator will want to review its policies based on the reports of abysmal customer service throughout the event.

Eurostar took immediate action to install finer filters on the engine intakes and trains were put back into service on Tuesday, the 22nd. The company has also stated it will reimburse passengers for the delay, but this solution will take longer to implement.

The entire root cause analysis investigation so far is shown on the downloadable PDF. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page. Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals. To view the PDF, click on “Download PDF” above.

By Kim Smiley

On October 21, 2009, Northwest Airlines Flight 188 left San Diego and overshot its intended destination, Minneapolis-St. Paul by about 150 miles. Luckily, the incident resulted in a safe landing at the intended destination, but the circumstances surrounding the flight remain vague and unsettling.

One of the strangest facts that have come out is that the plane lost contact with air-traffic controllers for one hour and 18 minutes.  In the post 9/11 aviation environment, controllers are very sensitive to planes that quit responding to communications.  The Federal Aviation Administration had contacted military authorities about the possibility of terrorism.  Fighter jets were ready to respond and prepared to intercept the plane if necessary.

So what happened?  How did the pilots overshoot the airport by such a significant amount without realizing their mistake?

Initial reports were that the pilots stated that they were in a heated discussion and simply lost situational awareness, but many aviation experts have stated it is unlikely that pilots would miss repeated hails for over an hour because of an argument.  Other reports have speculated that maybe both pilots fell asleep.

The most recent information to come out is that the pilots were using their laptops during the time they failed to respond to hails.  The pilots stated that they both were working on laptops and that they were discussing monthly flight crew scheduling.

Details concerning the overshoot are still being investigated, but an initial root cause analysis can be started to help document the investigation as it progresses.  This is what an Outline could look like at this stage:

A preliminary Cause Map can be started at this stage of an investigation.  As more information is known a detailed Cause Map can be built to document all the relent information.

More data should be available soon.  The Cockpit Voice Recorder and the Flight Data Recorder have both been sent to the National Transportation Safety Board for analysis and interviews of all involved parties continue.

On October 28, it was announced that the FAA has revoked the licenses of the two pilots involved because they violated several federal regulations, including fail to comply with air traffic control instructions and operating carelessly and recklessly. There are no currently specific federal rules banning the use of laptops after the flight reaches 10,000 feet at this time.

By Kim Smiley

The Defense Advanced Research Projects Agency (known as DARPA) issued a request for ideas on how to clean up orbital debris, commonly known as space junk, last week. The term space junk refers to all the objects currently in orbit around earth that no longer serve a useful purpose.

Why would DARPA want to put effort into removing space junk?  Why is it a problem?

A root cause analysis of this issue can be performed.  The first step is to identify the problem.  Then the investigation can be documented as a Cause Map and the causes contributing to the space junk problem should be investigated. In this case, the problem is that space junk poses a threat to unmanned and manned spacecraft, including satellites.

Space junk comes from a variety of sources (which will be discussed later) and is a wide variety of sizes. Impacts with large debris (greater than 1 kilogram) can destroy spacecraft at orbital velocities.  The only protection currently available is to move the spacecraft out of the path of space junk. Impacts with tiny debris cause erosion damage and can substantially shorten the life span of spacecraft.  Solar panels and windows are especially vulnerable to this type of damage.

Destroyed spacecraft then become part of the problem as long as they remain in orbit as defunct space junk themselves.

In addition to nonfunctioning, dead spacecraft, some of the causes of space junk are boosters from past spacecraft launches, lost equipment, and debris from weapons testing.  These causes should all be added to the cause map.

The problems associated space junk continue to increase and with more and more debris is created in earth’s orbit.

The largest space debris incident in history occurred in 2007 after China performed an anti satellite missile test and intentionally blew up a defunct satellite.  This test also targeted a satellite in the most heavily populated area of earth’s orbit.

Currently, the Space Surveillance Network tracks more than 20,000 objects in orbit.  And this number only includes those large enough to track.  There are estimated to be thousands of objects too small to track currently in orbit.

Hopefully DARPA is able to find an effective solution to mitigate the problem and reduce the risk posed by space junk.

Click on the “Download PDF” bottom above to view an intermediate level Cause Map of this issue.

By Kim Smiley

A recent report by a White House panel of independent space experts says NASA’s current goal to return to the moon isn’t feasible with the current budget. The panel estimates that NASA would need about $3 billion extra a year beyond the current budget to continue with human space flight.

The budget shortfall is obviously a problem that may prevent NASA from meeting their overall organizational goals.  A root cause analysis built as a Cause Map can be created to understand how this issue developed.

In this case, the production goal is impacted because NASA is likely to be unable to meet the stated goal of a moon mission by 2010.  This is caused by the high cost of a moon mission, other budget considerations (such as the cost of possibly extending the moon mission and the International Space Station) and the limited NASA budget.  The causes of each of these can then be explored.

NASA has been working toward a return to the moon because five years ago then-President George W. Bush stated that NASA should work to return astronauts to the moon, with a proposed date of 2020.  NASA has already spent $7.7 billion working toward this goal, including the design and the construction of new rockets.

Part of the plan to pay for this venture was to retire the space shuttle in 2010 and deorbit the International Space Station in 2015, but the panel also recommended revaluating these deadlines, which would add additional budget pressure.

The panel found that extending the life of the space station beyond 2015 would allow a better return on the billions of dollars invested into it.  The panel also felt the space shuttle should be evaluated for possible life extension as well in order to continue to service the space station, since there is no viable alternative that will be developed in the necessary time frame.

NASA budget continues to be limited as national budget constraints increase.  In order to raise funds, the panel also recommended including other countries and private-for-profit firms in addition to increasing NASA budget.

This problem has no easy, clear solution.  Only time will tell how President Obama will choose to respond to these findings and if human space flight will continue to be a goal for NASA.

By Kim Smiley

In recent years, the cost of attending a college in the US has risen about three times faster than inflation and the average student loan amounts have increased accordingly.  Combine this with the highest unemployment rates of college graduates since 1979 (4.8% in May, up from 2.1% at the start of the recession) and lower starting salaries during recessions, and there are many recent graduations struggling to make their loan payments.

As with any problem, it is possible to perform a root cause analysis of the issue. To begin let’s assume the production goal of an individual considering college is to earn a comfortable living and the potential impact to this goal will be difficultly making loan payments.

The causes of this potential problem repaying loans could be unemployment after graduation, lower starting salaries for new hires during a recession and large loan payments.  The causes of each of these factors can then be explored.  Click on the Download PDF graphic above to view an intermediate level Cause Map with more causes added.

A recent USA Today article entitled “In a Recession, Is College Worth It? Fear of Debt Changes Plans” discussed how many students are rethinking their college plans.  Enrollment at community college is soaring and many students are choosing a less expensive option and skipping the big name private institutions.

This makes sense when considering the potential difficulty repaying college loans because the only cause that the student has direct control over is the size of the loan payments.

The bottom line is that each individual needs to think through their particular situation, consider how much the college costs and how much the starting salary for their particular degree is projected to be.  There are very real dangers in amassing large student loans without calculating the monthly payments and ensuring that they are within a realistic budget.

The reality is that some universities cost more and there is no guarantee that attending a more expensive college will result in a higher salary.  It may well be a smart decision to choose a less expensive option when selecting a college.

If you’re interested in reading an analysis of the 2009 Financial Mess, please click here.

By Kim Smiley

The partial meltdown of a core at the nuclear power plant at Three Mile Island is one of the most well known engineering disasters in US history.  Luckily, no one was injured and there was no significant environmental impact, but the potential for major issues was very real.  Three Mile Island also had a huge impact on the nuclear industry and required a major clean up effort.

Performing a root cause analysis of historical incidents is useful because there are a number of lessons learned that can often be applied across a variety of industries.

As is true with any complex system, there were many causes that contributed to the Three Mile Island incident.  At the most simplified level, cooling water flow was stopped to the primary system (the nuclear portion).  The primary system then started to heat up, increasing the pressure to the point that a relief valve lifted.  The relief valve then failed to reseat and a large volume of coolant was lost.  The core eventually overheated because it was uncovered due to the loss of coolant.

Another factor that contributed significantly to the Three Mile Island incident was operator action during the casualty, which occurred over several shifts.  Had operators been able to understand the status of the plant in a timelier manner, the plant could have been put into a safe condition.

At first glance, it’s easy to stop at this point and use a term like “operator error”, but a thorough analysis requires more digging. Even if the technology being considered is radically different than a nuclear power plant, there are many lessons that can be learned from studying how the control room design impacted the operator actions during the incident.

The design of the control room significantly contributed to the operators’ inability to identify plant conditions.  The control room was huge with hundred of instruments to monitor, some of which were on the back of the control panels and couldn’t be viewed in the normal watch standing locations.  Dozens of alarms, both audible and flashing lights, went off in a very short period of time without any obvious priority.  The alarms continued throughout the casualty and the sheer volume of information was nearly impossible to interpret accurately.

Many industries continue to benefit from the lessons learned from the design of the control room.

For more detailed information on the Three Mile Island accident, please see the NRC’s Three Mile Island fact sheet.