Root Cause Analysis Information

Attempted Bombing of Flight 253

December 31, 2009

Despite constantly increasing airport security, a man suspected of terrorism was able to board a flight from Amsterdam to Detroit with ~80 grams of explosive and a liquid detonator. However, the device did not detonate, likely saving the plane.
Had the explosive detonated, it may have caused the loss of the plane, resulting in the deaths [...]

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Stuck in the Chunnel …

December 23, 2009

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 [...]

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Toyota Recall: Problems, Interim Solutions and Permanent Solutions

December 18, 2009

On September 29, 2009, Toyota/Lexus issued a safety advisory that some 2004-2010 model year vehicles could be prone to a rapid acceleration issue if the floor mat moved out of place and jammed the accelerator pedal. Although the recall is only applicable in the U.S. and Canada because of the type of floor mats used, [...]

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Airlink Incidents: Viewing Trends in Visual Form

December 10, 2009

Over the past three months, South Africa’s Airlink airline has had four incidents, ranging from embarrassing to fatal. Four similar incidents such as these start to point out a trend, which should be investigated to improve processes and increase safety. But how do we start the investigation?
In the Cause Mapping root cause analysis method, we [...]

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Another Train Collision for the Washington D.C. Metro

December 3, 2009

In the early morning hours of Sunday, November 29th, after the Washington D.C. Metro shut down for the night, train 902 pulled into the West Falls Church station for cleaning. However, instead of stopping just behind the parked train already on the tracks, it rammed into it.
We can put this incident into a Cause Map, [...]

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Barge Grounds Off Virginia Beach

November 18, 2009

At approximately 11:00 p.m. on October 12th, 2009, the two 500,000 lb strength towlines connecting La Prinsesa barge to its tug broke free.  The tug was unable to recapture the ship, and it drifted for about seven hours in heavy seas caused by a wind-driven rain storm before grounding at Sandbridge Beach in Virginia, just [...]

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How to Determine Your Organization’s Goals

November 12, 2009

The first step of the Cause Mapping strategy of root cause analysis is to define the problem with respect to the organization’s goals.  In order to do this, you need to know what an organization’s goals are.  While we provide Cause Mapping root cause analysis templates that will give you an idea of where [...]

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Damage to the San Francisco-Oakland Bay Bridge (Again)

November 6, 2009

In a previous blog, I wrote about the impressively quick repairs to the San Francisco-Oakland Bay Bridge.  These repairs allowed the heavily-traveled bridge to reopen only an hour and a half late from scheduled repairs, despite unexpectedly finding a cracked eyebar during that time.
However, during evening rush hour on October 27, less than 2 months [...]

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Missed by 150 Miles?

October 28, 2009

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 [...]

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Genesis Spacecraft Crash

October 15, 2009

The mission of the Genesis spacecraft was to collect the first samples of the solar wind and return the samples to earth to be analyzed. The goal was to provide fundamental data to help scientists determine the composition of the sun and learn more about the formation of our solar system.
Unfortunately, during descent on September [...]

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