Tag Archives: holiday

Root Cause Analysis - Incident Investigation

The Force Was NOT With Them!

By Jon Bernardi

A long time ago, in a galaxy far, far away, the Empire tried to use their fancy Death Star to keep the member systems in line. This plan did not work out very well, as Death Star One (DS-1) was not able to fulfill its mission of empowering galactic domination! DS-1 had travelled across the galaxy to quell the rebellion at the rebel base on Yavin 4, but did not count on the über-Force of the Rebel Alliance. The Empire did not realize the power of the good side of the Force as the rebels overcame all odds and were able to destroy DS-1. We can do an analysis of the incident to determine the system of causes for the destruction and show those causes visually in a Cause Map.

As much as the Emperor and his minions would not like to see this published, we begin by looking at how the Empire’s goals were impacted. We start by developing an outline of the incident. You might suspect that different factions within the Empire see this problem differently! Some don’t believe there is such a thing as “The Force” and place their faith in the power of the machine. Others use the Dark Side to exploit the mortal weaknesses of the players. The goals of the Empire are impacted in a number of ways: DS-1 is ultimately destroyed, with loss of life, and loss of a dominant-style weapon. The Rebel Alliance has gained a toe-hold against the Empire! We use the impact to the goals as the first effects of our cause-and-effect relationships and will use the disparate view of “the problem” to help us with the branches of the Cause Map.

We already know that DS-1 had planet-busting capabilities, as demonstrated convincingly at Alderaan, Princess Leia’s adopted planet. This may have led the Empire’s power structure to doubt the “Power of the Force” and put their trust in a technological titan, “The ultimate power in the universe!” Even after the plans for the station had been obtained by the Rebellion, the commander of DS-1 still disregarded any concern of vulnerability in his unsinkable marvel. In a remarkable display of hubris, the Empire allows the small band of rebels aboard the Millennium Falcon to escape with the stolen plans for DS-1. The Empire intends to follow them, find the rebel base, and wipe out the rebellion once and for all!

Another branch of the Cause Map follows the path of the stolen plans and the re-awakening of the Force on the planet Tatooine. As we analyze this section of the map, we can see the convergence of causes that led to the technical experts of the Rebel Alliance finally obtaining the plans for DS-1, analyzing them and discovering the dreaded “thermal exhaust port” – (guess even a DS has to have a tailpipe!).

Even a long time ago, we see causes in multiple areas coming together to form the overall picture of the incident. The plucky Rebellion, had THE FORCE with them!

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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

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

By ThinkReliability Staff

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.

Root Cause Analysis - Incident Investigation

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.