Tag Archives: Olympics

Root Cause Analysis - Incident Investigation

Olympic Track Worker Hit By Bobsled

By Kim Smiley

A worker at the bobsled track for the Sochi Winter Olympics was hit by a bobsled on February 13, 2014.  The worker suffered two broken legs and a possible concussion, but is reported to be stable after undergoing surgery.  There was also minor damage done to the track.  Part of a lighting system suspended from the ceiling was replaced and time was needed to clean small plastic shards off the ice.

Investigation into this accident is still underway, but the information that is available in the media can be used to build an initial Cause Map. One of the advantages of using Excel to build Cause Maps is that they can be easily modified to incorporate additional information once the investigation is complete.

When beginning the Cause Mapping process, the first step is to fill in an Outline with the basic background information for an issue.  How an incident impacted the overall organizational goals is also documented on the bottom half of the Outline.  Once the Outline is completed, the Cause Map is built by asking “why” questions. (Click on “Download PDF” above to view a high level Cause Map and Outline for this accident.)

So why was the worker hit by a bobsled?  This occurred because a forerunner sled was sent down the track while the worker was on the track.  The forerunner sled was on the track because they are used to test the track prior to training runs and competitions, and training was scheduled later that day.  Forerunner sleds ensure that ice conditions are good and that all systems, like the timing system, are functional.  People at the top of the track can’t see the entire track so there wasn’t an easy way for them to identify the position of the worker prior to running the sled.  Initial reports are that the normal announcements were made to the workers prior to running the forerunner sled so it doesn’t appear that the people on the top of the track had any reason to suspect a problem.

The worker was on the track doing work to prepare it for the training runs and competition scheduled that day.  We can safely assume that he was unaware that the forerunner sled was running the track at the same time.  Investigators have determined that the worker was using a loud motorized air blower and believe he was unable to hear both the announcement and the approaching bobsled.  Two other workers were also working on the track, but they were able to scramble out of danger as the bobsled approached.  Until the investigation is complete, it won’t be clear if other factors were involved, but it seems the use of loud equipment played a role in the accident.

The final step in the Cause Mapping process is to find solutions to reduce the risk of a problem reccurring.  It appears that the current method of letting workers know to clear the track isn’t adequate in all situations.  Officials will need to modify the process, especially when loud equipment is in use, to ensure the safety of all workers.  Workers need to be on the track at times in order to do their jobs and there needs to be a way to ensure they have moved to a safe location prior to any sled running the track.

It’s worth noting this is not the first time someone has been hit by a bobsled. In 2005, recent silver medalist skeleton racer Noelle Pikus-Pace was hit by a bobsled.  She shattered a leg and ended up missing the 2006 Turin Olympics as a result.  This accident occurred on a different track, but it highlights the dangers of bobsled tracks and the important of ensuring safety.

Root Cause Analysis - Incident Investigation

Concerns Raised About Safety of Olympic Slopestyle Course

By Kim Smiley 

One of the stories making headlines leading up to the start of the 2014 Winter Olympics was concern about the safety of the slopestyle course.  There were early rumblings about the slopestyle course, especially after a few falls during training runs, but the media interest intensified after well-known snowboarder Shaun White withdrew from the event.   There is also a heighten sensitivity to safety concerns after the death of a luger during the last Winter Olympics , which was the first  death in Olympic training or competition since 1964.

Safety of the athletes involved in the Olympics is obviously paramount, but media coverage of slopestyle course safety concerns is also an issue because it created negative press for both the Olympics and the host country.  A Cause Map can be built to help analyze this issue and illustrate all the factors involved with the controversy surrounding the Olympic slopestyle course. (To see a high level Cause Map of this issue, click on “Download PDF”.)

Several athletes fell during training runs on the slopestyle course, which led to questions about course safety.   There were some injuries on the course, the most notable being Torstein Horgmo of Norway who broke his collarbone during a practice run.  Horgmo was a favorite to medal in the event and was unable to compete after his injury, which has to be heartbreaking.

The course is different from the typical slopestyle course, partly because this is the Olympics and the designer wanted an exciting course.   Athletes are getting more air time from the jumps on the course because they are large step-down jumps where the landing zones are below the ramps.  Designing the first Olympic slopestyle course was a unique challenge and there was no precedent.

The weather has been an added challenge for the course designer.  The jumps were created intentionally oversized with plans to modify them as needed to help accommodate melting concerns in the above freezing weather.  It’s much easier to make a jump smaller, as opposed to larger, so designers would rather err on the size of too big.  Rain and warm weather also played havoc with plans to test the course.  A test event scheduled for last February was canceled because of weather.  Tests were scheduled to allow for more time to groom the course prior to the Olympics, but six days of massive rains pushed course completion past schedule.

It’s also worth noting that there is inherent danger in slopestyle.  Slopestyle is an extreme sport with snowboarders performing high intensity tricks in the air.  Factor in the pressure to bring the goods in an Olympic event and snowboarders are going to be pushing their limits.  The falls don’t all happen on the jumps, despite media focus on the large jumps on this course.  Torstein Horgmo’s Olympic-ending crash occurred on the stair set on top of the course.   While a course can be made too dangerous, there will never be a completely safe slopestyle course because of the nature of the sport.

Snowboarder Shaun White made headlines when he pulled out of slopestyle because of injury concerns, but it’s also important to remember that slopestyle isn’t White’s main event.  Although White failed to reach the podium this Olympics, he was the defending gold medalist on the halfpipe and wasn’t willing to risk his chance to compete in that event.  White suffered minor injuries from a crash on the slopestyle course and he didn’t want to impact his halfpipe chances by getting hurt worse.  Halfpipe came after slopestyle so the consequences of a potential injury were high for White.  I’m willing to bet he would have been much more likely to compete in slopestyle if it occurred after the halfpipe event.

The slopestyle course was modified after training runs, which is typical for an untested slopestyle course.  Forty to fifty centimeters were removed from the top deck of the jumps and snow was added to the knuckles of each landing.  The course crew has been credited for listening to athletes’ concerns and being responsive to issues. Lessons learned from the experience with the first Olympics slopestyle course will hopefully help things go smoother next time.  I hope the focus during the next Olympics is on the amazing athletes and not so much on the course.