Tag Archives: recall

Root Cause Analysis - Incident Investigation

Are Your Vehicle’s Tires Safe?

By ThinkReliability Staff

Four vehicle accidents between February and May of 2014 took 12 lives and injured 42 more. While the specifics of the accidents varied, all four were due to tread separations on tires. Later that year the National Transportation Safety Board (NTSB) hosted a Passenger Vehicle Tire Safety Symposium to address areas of concern regarding passenger vehicle safety due to tire issues. A special investigation report, which was adopted October 27, 2015, provides a summary of the issues and industry-wide recommendations to improve passenger vehicle safety.

There are multiple issues causing safety concerns with tires, and multiple recommendations to mitigate these safety risks. When dealing with a complex issue such as this, it can help to visually diagram the cause-and-effect relationships. We can do this in a Cause Map, or visual root cause analysis. This analysis begins with an impact to the organization’s goals. According to the NTSB report, tire-related accidents cause more than 500 deaths and 19,000 injuries every year in the US. Customer service (customers being members of the public who purchase and/or use tires) is impacted due to a lack of understanding of tire safety. The regulatory goal is impacted due to a lack of tire registration, and the production goal is impacted due to a low recall completion rate. Lastly, the property goal is impacted due to tires that are improperly maintained.

Cause-and-effect relationships are developed by beginning with an impacted goal (in this case, the deaths and injuries) and asking “why” questions. In this case, the deaths and injuries are due to tire-related accidents, of which there are about 33,000 every year in the US. Tire-related accidents includes accidents that are due to tire issues (such as tread separation) caused by improper maintenance or an unrepaired manufacturing issue with a tire (specifically those resulting in a tire recall). While the NTSB is recommending the promotion of technology that may reduce the risk of tire-related accidents, they also made recommendations that can reduce the risk of these accidents in the near term.

From 2009-2013, there were 3.2 million tires recalled in 55 safety campaigns. However, 56% of recalled tires remain in use, because of very low recall work completion rates. In a typical tire recall, only about 20% of recalled tires are returned to the manufacturer. (In comparison, about 78% of recalled cars are repaired.)   Many tires aren’t registered, and if they aren’t, it’s difficult to reach owners when there are recalls. Independent dealers and distributors, which sell 92% of tires in the US, aren’t required to register tires. While it is possible for consumers to look up their own tires to determine if they’ve been recalled, it’s difficult. The full tire identification number may not be printed in an accessible location, and the National Highway Traffic Safety Administration (NHTSA) website for tire recalls was found to be confusing.

The NTSB has recommended that tire manufacturers include the full tire identification number on both the inboard and outboard side walls of each tire so it can be more easily found by consumers. The NTSB has also recommended that the NHTSA, with the cooperation of the tire industry and Congress, if necessary, improve its recall site to allow search by identification number or brand and model, and improve registration requirements and the recall process.

Regarding improper maintenance, the report found that 23% of tire-related crashes involved tire aging and that 50% of drivers use the wrong tire inflation pressure, 69% have an underinflated tire, 63% don’t rotate their tires, and 12% have at least one bald tire. The report found that consumers have an Inadequate understanding of tire aging and service life and recommends developing test and best practices related to tire aging, and developing better guidance for consumers related to tire aging, maintenance and service life.

The NTSB has issued its own Safety Alert for Drivers, which includes the following guidance:

– Register new tires with the manufacturer

– Check your tire pressure at least once a month

– Inflate your tires to the pressures indicated in your vehicle owner’s manual (not on the tire sidewall)

– When checking tire pressure, look for signs of damage

– Keep your spare tire properly inflated and check it monthly for problems

– Rotate, balance and align your tires in accordance with your vehicle owner’s manual

– If you hear an unusual sound coming from a tire, slow down and have your tires checked immediately

To view the Cause Map, including impacted goals and recommendations, click on “Download PDF” above. Or, click here to read the NTSB’s executive summary.

 

Root Cause Analysis - Incident Investigation

Volkswagen admits to use of a ‘defeat device’

By Kim Smiley

The automotive industry was recently rocked by Volkswagen’s acknowledgement that the company knowingly cheated on emissions testing of several models of 4-cylinder diesel cars starting in 2009.  The diesel cars in question include software “defeat devices” that turn on full emissions control only during emissions testing.  Full emissions control is not activated during normal driving conditions and the cars have been shown to emit as much as 40 times the allowable pollution.   Customers are understandably outraged, especially since many of them purchased a “clean diesel” car in an effort to be greener.

The investigation into this issue is ongoing and many details aren’t known yet, but an initial Cause Map, a visual format for performing a root cause analysis, can be created to document and analyze what is known.  The first step in the Cause Mapping process is to fill in a Problem Outline with the basic background information and how the issue impacts the overall organizational goals.  The “defeat device” issue is a complex problem and impacts many different organizational goals.  The increased emissions obviously impacts the environmental goal and the potential health impacts of those emissions is an impact to the safety goal.  Some of the specific details are still unknown, like the exact amount of the fines the company will face, but we can safely assume the company will be paying significant fines (on the order of billions) as a result of this blatant violation of the law.  The Volkswagen stock price also took a major hit and dropped more than 20 percent following the announcement of the diesel emissions issues.  It is difficult to quantify how much the loss of consumer confidence will impact the company long-term, but being perceived as a dishonest company by many will certainly impact their sales.   A large recall that will be both time-consuming and costly is also in Volkswagen’s future.  Depending on the investigation findings, there is also the potential for criminal prosecution because of the intentional nature of this issue.

Once the overall impacts to the goals are defined, the actual Cause Map can be built by asking “why” questions.  So why did these cars include “defeat devices” to cheat on emissions tests?  The simple answer is increased profits.  Designing cars that appeared to have much lower emissions than they did in reality allowed Volkswagen to market a car that was more desirable. Car design has always included a trade-off between emissions and performance.  Detailed information hasn’t been released yet, but it is likely that the car had improved fuel economy and improved driving performance during normal driving conditions when full emissions control wasn’t activated. Whoever was involved in the design of the “defeat device” also likely assumed the deception would never be discovered, which raises concern about how emissions testing is performed.

The design of the “defeat device” is believed to work by taking advantage of unique conditions that exist during emissions testing. During normal driving, the steering column moves as the driver steers the car, but during emissions testing the wheels rotate, but the steering column doesn’t move.  The “defeat device” software appears to have monitored the steering column and wheels to sense when the conditions indicated an emissions test was occurring.  When the wheels turned without corresponding steering wheel motion, the software turned the catalytic scrubber up to full power, reducing emissions and allowing the car to pass emissions tests. Details on how the “defeat device” was developed and approved for inclusion in the design haven’t been released, but hopefully the investigation into this issue will be insightful and help understand exactly how something this over the line occurred.

Only time will tell exactly how this issue impacts the overall health of the Volkswagen company, but the short-term effects are likely to be severe.  This issue may also have long-reaching impacts on the diesel market as consumer confidence in the technology is shaken.

To view an Outline and initial Cause Map of this issue, click on “Download PDF” above.

Root Cause Analysis - Incident Investigation

DELAY OF RECALL REPAIRS FIRES UP NHTSA

By ThinkReliability Staff

On June 18, 2013, the manufacturer of Jeep Grand Cherokee and Liberty sport-utility vehicles (SUVs) recalled 1.56 million vehicles due to a risk of fuel tank fires during rear-end collisions. At the time of the recall, the National Highway Traffic Safety Administration (NHTSA) linked 51 deaths to the fuel tank fires. Although a fix was accepted in January, parts won’t be available to owners until August.

The NHTSA is concerned about this delay. Says O. Kevin Vincent, NHTSA Chief Counsel, “For many owners, a recall remedy deferred by parts availability easily becomes a defect remedy denied. Moreover, additional delays in implementing this recall with inure to Chrysler’s benefit at the expense of vehicle owner safety.”

Even without full information, a Cause Map can begin to develop the cause-and-effect relationships that led to an issue. As more information is provided, more detail can be added to the Cause Map.

The analysis begins by determining the impacts to the organization’s goals. In this case, the safety goal is impacted by the 51 deaths that were determined to have resulted from gasoline fires as a result of the recall issue as well as 4 additional deaths that have occurred since the recall, according to the executive director of watchdog group Center for Auto Safety. The delay in the repairs for the recall issue can also be considered an impact to the customer service and production goals.

Beginning with one of the impacts to the goals, asking “why” questions builds the Cause Map, a visual root cause analysis. Beginning with the deaths that have occurred as a result of the recall issue since the recall took place, asking “why” questions helps determine that the deaths resulted from the issue at the heart of the recall (the increased risk for gasoline fires) and the delay in repairs from the recall. (Had the repairs been implemented more quickly, the number of deaths as a result of the issue may have been reduced.)

The increased risk of gasoline fires occurs from an increased risk of fuel tank rupture in the event of a rear-end collision because the fuel tank, in an unusual design, is located behind the rear-most axle, which provides inadequate protection. The fix for the recall issue is to add a trailer hitch, which provides an additional distance between another vehicle and the fuel tank in a rear-end collision (but it should be noted will protect only against “lower to medium-speed rear-end crashes”).

Although the addition of trailer hitches was recommended by the manufacturer at the time of the recall, a supplier was not selected until December. The manufacturer has stated that it was finding new suppliers to deal with the higher-than-normal demand for these parts. It’s also possible that the manufacturer was waiting for the NHTSA to approve the fix, which occurred in January. The NHTSA was doing additional testing to ensure that the fix would be effective. After the supplier was selected, it took nearly two months for a purchase order to be issued and five months for production to begin. The reasons for this part of the delay are unknown, and are expected to be provided to the NHTSA near-term.

The delay starting production is one thing; another concern is the amount of time it will take before enough parts are available. The supplier originally selected could manufacture 1,323 Liberty trailer hitches and 882 Grand Cherokee trailer hitches a day, meaning that if all 1.56 million vehicle owners participated in the recall, it would take 4.7 years to produce enough trailer hitches. Currently, legal requirements are only that manufacturers are required to make repairs in a “reasonable time”, although most manufacturers begin repairs within about 60 days of notifying the NHTSA. This case may force the NHTSA to define what a “reasonable time” actually is.

The latest update from Chrysler is that the trailer hitch supplier has increased production capacity and will be able to meet the demand by March of 2015. Chrysler also said that the NHTSA over-estimated the number of hitches required for the recall because the calculations didn’t account for vehicles that are no longer in use or those already equipped with hitches.

To view a timeline, Outline and Cause Map of this issue, please click “Download PDF” above. Or, click here to learn more.

 

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Root Cause Analysis - Incident Investigation

Nearly 2.6 million GM Vehicles Recalled, Costs Soar to 1.3 Billion

By Kim Smiley

During the first quarter of 2014, General Motors (GM) recalled 2.6 million vehicles due to ignition switch issues tied to at least 13 deaths.  Costs associated with the issue are estimated to be around $1.3 billion and, possibility even more damaging to the long term health of the company, is the beating the company’s reputation has taken.

The ignition switch issues are caused by a small, inexpensive part called a switch indent plunger.  An ignition switch has four main positions (off, accessories, on, and start) and the switch indent plunger holds the ignition switch into position.  In the accidents associated with the recent recall, the ignition switch slipped out of the on position and into the accessories position because the ignition switch plunger didn’t have enough torque to hold it in place.  When the ignition is put into the accessories mode, the car loses both power steering and power braking, and the air bags won’t inflate.  It’s easy to see how a situation that makes a car less safe and more difficult to control can quickly create a dangerous, or even deadly, situation.  Additionally, it’s important to know the problem is most likely to occur when driving on a bumpy surface or if a heavy key ring is pulling on the key.

The other key element of this issue is how the problem has been handled by GM.  There are a lot of hard questions being asked about what was known about the problem and when it was known.  It is known that the faulty part was redesigned in 2006 to address the problem, but the new design of the part wasn’t given a new part number as would normally be done.  Multiple federal inquiries are working to determine when it was known that the faulty parts posed a danger to drivers and why there was such a long delay before a recall was done.  The fact that the redesigned part wasn’t assigned a new part number has also lead to questions about whether there was an attempt to cover up the issue. GM is not civilly liable for deaths and injuries associated with the faulty ignition switches because of its 2009 bankruptcy, but the company could potentially be found criminally liable.

No company ever wants to recall a product, but it’s important to remember that how the recall is handled is just as important as getting the technical details right.  Consumers need to believe that a company will do the right thing and that any safety concerns will quickly and openly be addressed.  Once consumers lose faith in a company’s integrity the cost will be far greater than the price of a recall.

If you drive a GM car, you can get more information about the recall here.  The recalled models are Chevrolet Cobalts and Pontiac G5s from the 2005 through 2007 model years; Saturn Ion compacts from 2003 through 2007; and Chevrolet HHR SUVs, and Pontiac Solstice and Saturn Sky sports cars from 2006 and 2007.

To view the Outline and Cause Map showing the root cause analysis of this issue, please click “Download PDF” above.  Or click here to read more.

Root Cause Analysis - Incident Investigation

Toyota Recalls Millions of Vehicles Because of Fire Risk

By Kim Smiley

On October 11, 2012, Toyota announced a recall of 7.4 million vehicles worldwide due to a potential fire hazard.  This newest recall comes on the heels of the heavily publicized unintended acceleration issue and puts Toyota once again in an unwanted spotlight.

A Cause Map, a visual format for performing a root cause analysis, can be built to help analyze this issue.  The first step in building a Cause Map is to create an Outline that lays out how the issue impacts the overall goals of an organization.  In this example, the safety goal is impacted because of the potential for injuries and car accidents.  The production goal is impacted because of the effort needed to recall millions of vehicles.  The customer service goal is also impacted because of the negative publicity that a recall of this size will generate.  After the impact to the goals is determined, “why” questions are asked to determine what causes contributed to the issue and to create the Cause Map.

Starting with the production goal, we would ask “why” millions of vehicles were being recalled.  This is happening because there is a component that may need to be repaired, the component is in many vehicles and there is a potential for injuries if the component isn’t repaired.  A component needs to be repaired because the power-window switches pose a fire risk.  Some of the power-window switches feel sticky when operated and if some commonly available lubricants are applied it will create a fire hazard because the switch can melt.  There are millions of these power-window switches to repair because they were used across multiple models for several years because using standard parts is usually cheaper.  There is a potential for injuries because a fire starting in the power-window switch while the car is driving would be pretty distracting.

This recall will generate negative publicity because it is a huge recall, the a largest vehicle recall since Ford Motor Co recalled 7.9 million vehicles in 1996, and the timing is a bit unfortunate since it comes shortly after the unintended acceleration issues that resulted in large recalls.  In fact, some of the vehicles being recalled this round are the same vehicles that have had previous recalls, a fact that probably isn’t reassuring to owners.

The good news is that the fix for this problem is relatively simple beyond the innate hassle of taking a vehicle to the dealer.  The recall consists of a technician inspecting, disassembling and applying approved fluorine grease to the power-window switch, improving the sticky operation and decreasing the likelihood that some handy soul might apply an unapproved lubricant and inadvertently melt the part.

To view a high level Cause Map of this issue, click on “Download PDF” above.

Root Cause Analysis - Incident Investigation

1982 Tylenol Tampering

By ThinkReliability Staff

In 1982, 31 million bottles of Tylenol were recalled after seven deaths from cyanide poisoning.  After an investigation, higher than lethal doses of cyanide were found to have been inserted into bottles of Extra-Strength Tylenol capsules in retail stores in the Chicago area. Tylenol’s manufacturer, Johnson & Johnson, immediately took action and recalled all Tylenol products.

Although the reason for the poisoning is unclear – the suspect has still not been caught, though interest in the case has recently been revived – what was clear is that the ability to tamper with a product in such a malicious way without the tampering being evident contributed to the deaths.  As a result of this issue, capsules (which are much easier to insert foreign objects into than solid pills) decreased in use, and tamper-evident packaging became used for many products.

Although the manufacturing and packaging process were not implicated in the poisonings (the adulterated packages were from different plants, but all came from stores within the Chicago area), there was concern that Tylenol would never again be popularly accepted.  However, Johnson and Johnson’s quick and effective action in the immediate recall of all products and public relations campaigns to urge people not to use products until the issue had been resolved has been considered a playbook on how to conduct an effective recall and is believed to have directly contributed to the resurgence in the popularity of Tylenol shortly after the issue.  (See “How Effective Public Relations Saved Johnson and Johnson“.)

Even though this case hasn’t been resolved, and the killer still remains unknown, it is possible to examine the issue with a Cause Map.  Because this case has stretched over many years, a timeline can help to sort through information.  The outline contains the many impacts to the goals related to the issue, and the Cause Map sorts through causes – both “good” and “bad” – related to the issue.  Solutions implemented to decrease the ability to tamper with consumer products are also noted.

Root Cause Analysis - Incident Investigation

Salmonella Recall

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By Kim Smiley

A number of food products have been recalled recently because of potential salmonella contamination.  The recall list is still growing and has the potential to affect thousands of items in nearly every aisle at the grocery store.

The contamination originated in hydrolyzed vegetable protein (HPV) which is a common, inexpensive salty and savory flavor enhancer used in a variety of products.  All HPV from Basic Food Flavors of Las Vegas made since September 17, 2009 has been recalled.   For a list of all recalled items and more information, please visit the Food and Drug Administration webpage.

The salmonella contamination occurred in the processing equipment at a one location, but HPV from that supplier was sold to food manufacturers nationwide.  HPV is a specialized product and there are only a few suppliers for it so issues at a single supplier have the potential to affect a significant percentage of the processed food supply.

The contamination was identified when a consumer of the Basic Food Flavors identified salmonella in a batch of HPV they had purchased and reported it to the FDA, utilizing the new FDA Reportable Food Registry.  The FDA then inspected Basic Food Flavors and found salmonella in the plant’s processing equipment.

The overall risk to the public is considered low.  No cases of illness from this contamination have been reported.  As long as products are heated to a sufficient temperature, either during the manufacturing process or cooked after purchase, the salmonella risk will be eliminated.  The highest risk products are ready to eat products such as chips, dips, and dip powder.

The investigation of this incident is still ongoing, but a basic root cause analysis can be started.  The safety goal is obviously impacted since salmonella can potentially cause illness and even death in the case of weakened immune systems.  In this case, the customer service goal would be impacted as well because the recall may affect customer confidence and sales of the recalled items.

Click on the “Download PDF” button to view an initial Cause Map of the salmonella contamination.  The Cause Map can be expanded as more details are available.

Root Cause Analysis - Incident Investigation

Toyota Recall: Problems, Interim Solutions and Permanent Solutions

by Kim Smiley

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, over 4 million vehicles are affected by the recall.

Although all the solutions to this problem have not yet been implemented, we can look at the issue so far in a Cause Map, or visual root cause analysis. First we define the problem. Here we could consider the problem the recall, or the acceleration problems. We can list all the models and years that are affected by the recall, and that the recall is limited to the U.S. and Canada.

We define the problem with respect to the organization’s goals. There have been at least 5 fatalities addressed by the National Highway Transportation Safety Administration (NHTSA), though some media outlets have reported more. Additionally, the NHTSA has reported 17 accidents (again, some claim more) and has received at least 100 complaints. The fatalities and accidents are impacts to the safety goal. Complaints are impacts to the customer service goal. The recall of more than 4 million cars is an impact to the production/schedule goal, and the replacement of the accelerator pedals and floor mats as a result of the recall is estimated to cost $250 million, which is an impact to the property goal.

Once we’ve completed the outline, we can begin the Cause Map, or the analysis step of the process. The fatalities are caused by vehicle crashes resulting from a loss of control of the vehicle. The loss of control is caused by a sudden surge of acceleration, inability to brake, and sometimes an inability to shut down the engine of the car. Toyota says the sudden bursts of acceleration are caused by entrapment of the accelerator pedal due to interference from floor mats. Toyota refutes the possibility that there may be a malfunction in the electronic control system, saying it’s been ruled out by Toyota research.

The vehicles are unable to brake because the brake is non-functional when the accelerator pedal is engaged, as it is in these cases. Additionally, owners whose models are equipped with keyless ignition cannot quickly turn off their ignition. These models require the ignition button to be pressed for 3 seconds to prevent inadvertent engine stops, and the instructions are not posted on the dashboard, so owners who weren’t meticulous about reading (or remembering) instructions from the owners’ manual may not know how to turn off the car while moving at very quick speeds.

When the Cause Map is complete to a sufficient level of detail, it’s time to explore some solutions. In this case, the permanent solutions (which will reduce the risk of these accidents most significantly) to be implemented by Toyota are to reconfigure the accelerator pedal, replace the floor mats, and install a brake override system which will allow the brakes to function even with the accelerator pedal engaged. However, designing and implementing these changes for more than 4 million cars will take some time, so owners of Toyotas require interim solutions. Interim solutions are those that do not sufficiently reduce the risk for long-term applicability but can be used as a stop-gap until permanent solutions are put in place. In this case, Toyota has asked owners to remove floor mats, and has put out guidance that drivers who are in an uncontrolled acceleration situation should shift the engine into neutral, which will disengage the engine and allow the brake to stop the car.

View the high level summary of the investigation by clicking “Download PDF” above.

Learn more about the recall at the NHTSA website.

Root Cause Analysis - Incident Investigation

UPDATE: US Beef Recall

By Kim Smiley

I wanted to add a few more interesting facts on the recent beef recall as the ramifications continue to surface.  As a quick recap, on February 17, 143 millions pounds of beef were recalled.  For perspective, that’s enough beef to make every person in the US about two hamburgers.  The scope of the recall is rapidly expanding and it may become the largest food recall in US history.  The full magnitude of the recall is just now becoming apparent because it takes weeks to track down all the products containing the recalled beef.

Take a second to think of all the products in a grocery store that contain beef and you can imagine how large this recall is likely to become.  The amount of food that is going to be destroyed is mind boggling and the cost is likely to be in the hundreds of millions of dollars.  Keep in mind that no cases of illness have been reported, a large amount of the beef has already been consumed, and the U.S. Department of Agriculture classifies the risk to consumers as remote.  Does it make sense to destroy all this food? As you consider the scope of the recall, I ask you also to consider a root cause analysis of the problem.

The previous blog asked the question, what is the best approach to prevent this type of problem from happening again? I still don’t now the answer, but I do know that a recall alone does not solve the initial problems that caused the issue.  What cause really lead to sick cows being mistreated and then slaughtered for human consumption?  A recall deals with the problem after the fact and a good solution would change something in the process prior to the meat entering the food chain.  The USDA has stated that it will not be increasing inspections at food processing plants and I haven’t found any evidence that other changes are being made in the work process at the slaughterhouses.  I’ll be continuing to cook my meat well done.