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The Solution to America’s Most Unexpectedly Dangerous Mammal

By ThinkReliability Staff

It’s hard to imagine that the mammal responsible for over 200 human deaths in America each year is the cute, cuddly…. deer.  These beautiful and seemingly harmless animals are hardly malicious.  Instead, they are in the wrong place at the wrong time, resulting in more than one million deer / vehicle collisions each year.  While the drivers have partial responsibility in these collisions, it seems that changes in the food chain have also contributed to this situation.   

In the 1800s, cougars (also called pumas or mountain lions) could be found roaming across the United States and Canada.  However, beginning in the early 1900s, states began implementing bounty programs enticing hunters to kill cougars.  The goal was to protect livestock and humans from these seemingly dangerous animals.  By the 1950s, the cougar population was primarily limited to areas west of the Rocky Mountains.  As the food chain predicts, the absence of a predator resulted in the overpopulation of its prey.  As the deer population increased, the probability for deer / vehicle collisions also increased.  

Expensive solutions have been considered to help decrease the collision rate, including deer culling, contraception and highway crossings.  However, it seems that nature may now be working towards its own natural solution.  As the bounty programs were removed in the 1960s and 1970s, the cougars have slowly begun migrating back towards the east.  A recent study published in Conservation Letters suggests that repopulation of cougars in the Eastern portion of the US could prevent 708,600 deer / vehicle collisions and 155 deaths over the next 30 years.   (The original fear of cougars attacking humans seems unfounded.  According to The Cougar Network, “Cougars are a retreating animal and very wary of people. Within the United States and Canada since 1890, there have been less than 100 attacks on humans, with about 20 fatalities. Encountering a cougar, let alone being attacked, is incredibly rare.”) 

A Cause Map is a helpful tool to dissect the cause-and-effect relationships contributing to a problem or situation.   Starting with the goals that were impacted, the causes and effects can be linked to create a chain.   For this situation, we begin with the safety goal that is impacted by the many fatalities each year.  Asking ‘Why’ questions, we can dig deeper to understand what causes are behind the impacted goal.   

In this case, the fatalities are a result of car collisions with deer.  The collisions are due to two factors: the deer unexpectedly crossing the road and the fact that the driver didn’t see the deer in time to stop.  We can trace each of these causes one at a time, revealing more causes.  The deer unexpectedly crosses the road because deer are moving to new areas.  This is because deer are overcrowded and need to expand their habitat.  The overcrowding is due to the growing deer population, which is due to the decrease in natural deer predators.  This decrease is caused by the decline in the cougar population, which is a result of the bounty programs that were implemented in the early 1900s.  These bounty programs were motivated by fear that the cougars would endanger humans or livestock.   

Going back to the driver’s role in the situation, we see that the driver may not have seen the deer in time due to poor lighting because deer often travel at dawn or dusk, and the driver may not have been paying close enough attention perhaps because they were distracted.   A second goal, property, was also impacted in this situation because the vehicles are damaged or destroyed as a result of the collisions.   

The Cause Map is also helpful in that it allows us to document the evidence and potential solutions directly on the causes that they can impact.   For example, the statistics about the number of collisions each year, fatalities each year, and cougar population changes are included right below the causes that they support.   Similarly, possible solutions are added right above the causes that they can impact.  In this case, deer culling and contraception could help control the deer overcrowding, and special deer highway crossings could help mitigate the deer crossing the road unexpectedly.  However, nature’s solution seems to fit further back in the chain by impacting the cause that is the decrease in the cougar population.   Time will tell if this solution will, in fact, reduce the number of collisions and injuries as predicted. 

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

Root Cause Analysis - Incident Investigation

For the first time, autonomous car is at fault for a crash

By Kim Smiley

On February 14, 2016, the self-driving Google car was involved in a fender bender with a bus in Mountain View, California.  Both vehicles were moving slowly at the time and the accident resulted in only minor damage and no injuries.  While this accident may not seem like a very big deal, the collision is making headlines because it is the first time one of Google’s self-driving cars has contributed to an accident.  Google’s self-driving cars have been involved in 17 other fender benders, but each of the previous accidents was attributed to the actions of a person, either the drivers of other vehicles or the Google test driver (while they were controlling the Google car).

The accident in question occurred after the Google car found itself in a tricky driving situation while attempting to merge.  The Google car had moved over to the right lane in anticipation of making a right turn.  Sandbags had been stacked around a storm drain, blocking part of the right lane.  The Google car stopped and waited for the lane next to it to clear so that it could drive around the obstacle.  As the Google car moved into the next lane it bumped a bus that was coming up from behind it.  Both the driver of the bus and the Google car assumed that the other vehicle would yield.  The test driver in the Google car did not take control of the vehicle and prevent the car from moving into the lane because he also assumed the bus would slow down and allow the car to merge into traffic. (Click on “Download PDF” to view a Cause Map that visually lays out the causes that contributed to this accident.)

Thankfully, this collision was a relatively minor accident. No one was hurt and there was only relatively minor damage to the vehicles involved. Lessons learned from this accident are already being incorporated to help prevent a similar incident in the future. Google has stated that the software that controls the self-driving cars has been tweaked so that the cars will recognize that buses and other large vehicles may be less likely to yield than other types of vehicles. (I wonder if there is a special taxi tweak in the code?)

It’s also worth noting that one of the driving factors behind the development of autonomous cars is the desire to improve traffic safety and reduce the 1.2 million traffic deaths that occur every year.  The Google car may have contributed to this accident, but Google cars have so far generally proved to be very safe.  Since 2009, Google cars have driven more than 2 million miles and have been involved in fewer than 20 accidents.

One of the more interesting facets of this accident is that it raises hard questions about liability.  Who is responsible when a self-driving car causes a crash? The National Highway Traffic Safety Administration (NHTSA) recently determined that for regulatory purposes, autonomous vehicle software is a “driver” which may mean that auto manufacturers will assume greater legal responsibility for crashes.  NHTSA is working to develop guidance for self-driving vehicles, which they plan to release by July, but nobody really knows yet the impact self-driving cars will have on liability laws and insurance policies.  In addition to the technology issues, there are many legal and policy questions that will need to be answered before self-driving cars can become mainstream technology.

Personally, I am just hoping this technology is commercially available before I reach the age where my kids take away my car keys.

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

Make safeguards an automatic step in the process

By Holly Maher

On the morning of May 13, 2015, a parent was following his normal morning routine on his way to work.  He dropped off his older daughter at school and then proceeded to the North Quincy MBTA (Massachusetts Bay Transportation Authority) station where he boarded a commuter train headed to work.  When he arrived, approximately 35 minutes later, he realized that he had forgotten to drop off his one-year-old daughter at her day care and had left her in his SUV in the North Quincy station parking lot.  The frantic father called 911 as he boarded a train returning to North Quincy.  Thankfully, the police and emergency responders were able to find and remove the infant from the vehicle.  The child showed no signs of medical distress as a result of being in the parked car for over 35 minutes.

Had this incident resulted in an actual injury or fatality, I am not sure I would have had the heart to write about it.  However, because the impact was only a potential injury or fatality, I think there is great value in understanding the details of what happened and specifically how can we learn from this incident.  Unfortunately, this is not an isolated incident.  According to kidsandcars.org, an average of 38 children die in hot cars annually.  About half of those children were accidentally left in the vehicle by a parent, grandparent or caretaker.  While some people want to talk about these incidents using the terms “negligence” or “irresponsibility”, in the cases identified as accidental it is clear the parents were not trying to forget their children.  They often describe going into “autopilot” mode and just forgetting.  How many of us can identify with that statement?

On the morning this incident happened, the parent was following his typical routine.  After dropping off his older child at school, he went into “autopilot” and went directly to the North Quincy MBTA station, parked and left the vehicle to board the train.  His one-year-old daughter was not visible to him at that point because she was in the back seat of the vehicle in a rear facing car seat, as required by law.  Airbags were originally introduced in the 1970s but became more commercially available in the early 1990s.  In 1998, all vehicles were required to have airbags in both the driver and passenger positions.  This safety improvement, which has surely reduced deaths related to vehicle accidents, had the unintended consequence of putting children in car seats in a less visible position to the parents.  The number of hot car deaths has significantly increased since the early 1990s.

On the morning of the incident the ambient conditions were relatively mild, about 59 degrees Fahrenheit.  However, the temperature in a vehicle can quickly exceed the ambient conditions due to what is called the greenhouse effect.  Even with the windows down, the temperature in a vehicle can rise quickly.  80% of that temperature rise occurs within the first 10 minutes.

When the parent arrived at his destination, approximately 35 minutes later, he realized he had forgotten the infant and reboarded a train to return to the North Quincy station.  Thankfully, the parent also called 911 which expedited the rescue of the infant.  The time in the vehicle would obviously have been longer had he not called 911.

One other interesting detail about this incident is that the parent reported that he normally had a “safeguard” procedure that he followed to make sure this didn’t happen, but he didn’t follow it on this particular day.  It is unknown what the safeguard was or why it wasn’t followed.  This certainly makes an interesting point: we don’t follow safeguards when we know something is going to happen, we follow safeguards in case something happens.  As I told my daughter (who didn’t want to wear her seatbelt on the way from school to home because it “wasn’t that far”), you wear your seat belt not because you know you are going to get into an accident, you wear it in case you get into an accident.

The solutions that have been identified for this incident have been taken directly from kidsandcars.org.  They promote and encourage a consistent process to manage this risk not when you know you are going to forget, but in case you forget.  Consider placing something you need (phone, shoe, briefcase, purse) in the rear floor board so that you are required to open the rear door of the vehicle.  Always open the rear door when leaving your vehicle; this is called the “Look before you Lock” campaign.  Consider keeping a stuffed animal in the car seat; when the car seat is occupied, place the stuffed animal in the front seat as a visual cue/reminder that the child is in the car.  Consider implementing a process where the day care or caretaker calls if your child does not show up when expected.  This will minimize the amount of time the child might be left in the car.

For more information about this topic, visit kidsandcars.org.

Root Cause Analysis - Incident Investigation

Concrete slab smashes truck killing 3

By Kim Smiley

On April 13, 2015, a large section of a concrete barrier fell from an overpass onto a truck in Bonney Lake, Washington. A couple and their baby were in the vehicle and were all killed instantly. Investigators are working to determine what caused this accident and to determine why the road under the overpass remained open to traffic while construction was being done on the overpass.

A Cause Map, a visual method of root causes analysis, can be built to help understand this accident. More information is still needed to understand the details of the accident, but an initial Cause Map can be created now to capture what is known and it can be easily expanded to include additional information as it becomes available. A Cause Map is created by asking “why” questions and visually laying out the answers to show the cause-and-effect relationships. (Click here to learn more about basics of Cause Mapping.)

In this accident, three people were killed because the vehicle they were riding in was smashed by a large slab of concrete. The vehicle was hit by the concrete slab because it was accidently dropped and the truck was under the overpass at the time it fell because the road was open to traffic. (When two causes are both needed to produce and effect, the causes are listed on vertically on the Cause Map and separated by and “and”.) The road would typically have been closed to traffic while heavy work was performed on the overpass, but the work plan for the construction project did not indicate that any heavy work would be performed on the day of the accident.   At some point the actual work schedule must have deviated from the planned schedule, but no change was made in plan for managing traffic resulting in traffic traveling under the overpass while potentially dangerous construction was performed.

Investigators are still working to understand exactly why the concrete slab fell, but early indication is that temporary metal bracing that was supporting the concrete may have failed due to buckling. The concrete barrier on the overpass were being cut into pieces at the time of the accident so that they could be removed as part of a $1.7 million construction project to improve pedestrian access which included adding sidewalks and lights.

Once the details of what causes this tragic accident are better understood, solutions can be developed and implemented that will help reduce the risk of something like this happening again. To view a high level Cause Map of this accident, click on “Download PDF” above.

You can also read a previous blog “Girder Fell on Car, Killing 3” to learn more about a similar accident that occurred in 2004.

Root Cause Analysis - Incident Investigation

Distraction Related Accidents: Eyes on Road, Hands on Wheel, AND Mind on Task

By  Sarah Wrenn

Admit it – you’ve checked your phone while driving.  We’ve likely all been guilty of it at some point.  And despite knowing that we’re not supposed to do it – it’s against the law in most states and we understand that the distraction increases our risk of having an accident – we still do it.  Why?

On March 31, 2015, the National Transportation Safety Board (NTSB) held its first roundtable discussion on distractions within the transportation industry.  In 2015, the NTSB added “Disconnect from Deadly Distractions” to its “Most Wanted List of Transportation Safety Improvements for 2015.”  This list represents the NTSB’s priorities to increase awareness and support for key issues related to transportation safety.  Other critical topics include “Make Mass Transit Safer” and “Require Medical Fitness for Duty.”

Representatives from all modes of transportation, technology, law enforcement, insurance, researchers, advocates, and educators came together for discussion related to distractions facing vehicle operators.

“New technologies are connecting us as never before – to information, to entertainment, and to each other,” said NTSB Member Robert Sumwalt. “But when those technologies compete for our attention while we’re behind the wheel of a car or at the controls of other vehicles, the results can be deadly.”

Digging into the causes

So let’s take a look at some of the causes related to an accident where the operator is distracted.  In addition to the accident occurring because of the distraction, the level of driver expertise is also a factor.  A large effort has been made to raise awareness and provide education to teenage drivers.  This is in part because, as novice drivers, they have a more limited exposure to driving situations and may not have the ability to react as a more skilled driver.

Operators become distracted

We also want to understand the causes that led to the operator being distracted.  There is a distraction type (or mode) that was introduced, the duration of the distraction, and the individual’s inability to ignore the distraction that result in the operator distraction.  While the type of distraction plays a large role in taking the operator’s eyes off the road, hands off the wheel or mind off the task, the duration of the distraction also is a key factor.  For example, while one’s eyes remain on the road during a phone call, the duration of that call disengages the brain from the task for more time than the act of dialing the phone.  This is not to say that one of these actions is more or less impactful; it is important to note that they both play a role in distracting the individual.

It’s not just the text that is distracting

There are three primary forms of distractions – Visual (taking eyes off of the road), Manual (taking hands off of the wheel), and Cognitive (taking mind off of the task).  Visual and manual types of distractions are very easy to define and generally recognized as risky behaviors while operating a vehicle.  Cognitive distractions are less tangible and therefore more difficult to define.  Research and studies generally define cognitive distractions as when the individual’s attention is divided between two or more tasks.  While technology and activities such as texting or talking on the phone are typically identified as the primary forms of distraction, it is interesting to note that cognitive distractions such as allowing your mind to wander while operating a vehicle can be just as risky.  The AAA Foundation released a 2013 study “Measuring Cognitive Distraction in the Automobile.”  The study rates various tasks such as using a hands-free cell phone and listening to the radio according to the amount of cognitive workload imposed upon an operator.  The study concludes that “while some tasks, like listening to the radio, are not very distracting, others – such as maintaining phone conversations and interacting with speech-to-text systems – place a high cognitive demand on drivers and degrade performance and brain activity necessary for safe driving.”

The forum discussed the concept that ability to multi-task is actually a myth, with evidence and data to conclude that for certain types of activities multi-tasking is not only difficult, but impossible.  For example, tasks such as navigation and speech require the use of the same circuits within the brain.  As such, the brain cannot do both tasks at once.  Instead, the brain is switching between these tasks, resulting in a reduction of focus on the primary task (driving) while attempting to perform a secondary task (speaking).  Therefore, attempting to multi-task introduces a cognitive distraction that increases the risk of unsafe driving.

Just ignore it

Why don’t we just ignore the temptation to become distracted?

Our brains function by releasing serotonin and dopamine when an action occurs that makes us feel good.  Dr. Paul Atchley of the University of Kansas stated: “There is nothing more interesting to the human brain than other people.  I don’t care how you design your vehicle or your roadways, if you have technologies in the vehicle that allow you to be social, your brain will not be able to ignore them.  There are only two things we love, serotonin and dopamine.  The two reward chemicals that come along with all those other things that make us feel good.  There is really nothing more rewarding to us than the opportunity to talk to someone else.”

Surveys performed by various organizations have revealed a large percentage of people (sometimes 3 out of 4) that will admit to being distracted while driving.  Meanwhile, a staggering percent (upwards of 90%) will rationalize the behavior which is a sign of addiction.

Finally, the level of brain development controls our ability to respond to distractions.  For example, a teenager has a less developed fontal cortex than an adult which means, as Dr. David Strayer of the University of Utah explains: “Teens’ frontal cortex, the parts of the brain that do decision-making in terms of multitasking, are underdeveloped.”  Much of the focus on distracted driving is focused on teens and this is justified as their brain development is not yet complete.  It is, however, important to note that this is not just an issue for teens who can’t be separated from their phones or seniors who don’t understand them; this is an issue that crosses all demographics.  Level of brain development is just one factor.

So what can we do?

At the end of the day, we want to identify solutions that are going to effectively reduce the risk of having accidents related to distractions from occurring.  While there will always be some risk, it is key to take a comprehensive approach to education, technology, and policy.  Programs like EndDD.org and stopdistractions.org are focused on bringing awareness, education, and training to youth and adults about the risks of operating vehicles while distracted.  Technology can also be used in a variety of ways to reduce the risk of these types of accidents.  Sensors can be built into vehicles to identify distractions and provide alerts to drivers or apps can be used to disable functions of technology so the receipt of calls and texts are delayed.  Finally, establishing policies and laws that are realistic and enforceable is important so that individuals are held accountable for risky behaviors before an accident occurs.  No one single solution is going to reach everyone and no one single solution is going to eliminate the risk of deadly accidents.  Each one of these solutions has limitations, but they also have advantages.  With a balanced approach to raise awareness and education, provide resources and tools to drivers, and change the culture of what is acceptable while driving, we can reduce the amount of accidents and save lives.

References:

NTSB Roundtable: Disconnect from Deadly Distractions held March 31, 2015, from 9:00 a.m. – 4:00 p.m.

AAA Foundation: Measuring Cognitive Distraction in the Automobile, June 2013

Root Cause Analysis - Incident Investigation

Investigation Into the Fatal Crash of Commercial Space Vehicle is Underway

By Kim Smiley

On October 31, 2014, Virgin Galactic’s commercial space vehicle, SpaceShipTwo, tore apart over the Mojave Desert in California during its fourth rocket-powered test flight. One pilot was killed and the other seriously injured. An investigation is underway to determine exactly what caused the crash, but initial data indicates that the tail booms used to slow down the vehicle moved into the feathered position prematurely, increasing the aerodynamic force. This disaster has the potential to impact the emerging commercial space industry as regulators and potential passengers are reminded of the inherent dangers of space travel.

This issue can be analyzed by building a Cause Map, a visual method for performing a root cause analysis. An initial Cause Map can be built using the information that is currently available and then easily expanded as more data is known. The first step is to fill in an Outline with the basic background information of the incident. Additionally, the impacts to the overall goals are listed on the Outline to determine the scope of the issue. The Cause Map is then built by asking “why” questions.

Starting with the safety goal in this example: one pilot was killed and another was injured because a space vehicle was destroyed and they were onboard. (When two causes both contribute to an effect, they are both listed on the Cause Map and joined with an “and”.) SpaceShipTwo is designed to hold passengers, but this was a test flight to assess a new fuel so the pilots were the only people onboard. The space vehicle tore apart because the stress on the vehicle was greater than the strength of the vehicle. The final report on the accident will not be available for many months, but the initial findings indicate that the space vehicle experienced greater aerodynamic forces than expected.

The space vehicle used tail booms that were shifted into a feathered position to increase drag and reduce speed prior to landing. Video shows the co-pilot releasing the lever that unlocked the tail booms earlier than expected while the vehicle was still accelerating. It’s unclear at this time why he released the lever. The tail booms were not designed to move when unlocked and a second lever controls movement, but investigators speculate that the aerodynamic forces on the space vehicle while it was still accelerating caused them to lift up into the feathered position once they were unlocked. The vehicle disintegrated seconds after the tail booms shifted position, likely because of the aerodynamic forces in play.

After the final report is released, the Cause Map can be expanded to include the additional information. To view a high level Cause Map of this accident, 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.