I take many flights every year and so, getting to the plane on time is a fundamental requirement for getting my job done.  If I miss a flight, its important that I find out “why” and enact some sort of preventative measure to ensure that I don’t repeat that error.  So, when I missed a recent flight out of Chicago, it provided a perfect opportunity to do a self-investigation and a miniature Cause Map.

Here is the “Story”.

As I was leaving a client office I realized that there was time to get some Chicago Deep Dish Pizzas and take them home.  My family really loves it when I can bring something special back from a trip. I found a restaurant not far from the airport.  I was able to arrange preparation of the pizzas for transport.  Getting to the restaurant was more tricky than I had anticipated but I found a good parking spot so all was going smoothly.  I was actually rather proud of myself as I found I had arrived at the airport with time to spare.   As I approached the terminal I was confused by some of the signs and I turned into the airport departure and arrival area rather than rental car return area. Back-tracking required an extra 10 minutes to get to the rental car area.  Now, I would have to move quickly, but I would still make my flight.

I arrived at the rental car return area approximately 60 minutes prior to the scheduled flight departure. An item needed to be checked onto the aircraft and the requirement is 45 minute baggage check minimum.  Haste was needed to get from the rental car area (walking distance – no bus ride required) to the ticket counter.  Now, I was feeling rushed and, in my haste, I made an error.  I left my cell phone in the rental car.  Normally the cell phone would stay in my pocket or briefcase.  However the cell phone was left on the center console in the rental car. The console was black and the phone was black; I had scanned the area but hadn’t noticed it.  By the time I realized my error and worked with the rental car company to retrieve the car and the phone, only fifteen minutes remained before the scheduled flight departure and I still needed to get through security. 

Needless to say as I walked up to the gate the door had just closed.  The airline officials were more than accommodating and no additional airline costs were required; however, an overnight hotel stay was required.

After a failure of any kind, it is human nature to look for someone to blame.  My mind went through a list of “if only’s”:  if only the restaurant had been in a better location, if only the rental car company hadn’t taken fifteen minutes to retrieve my car, if only the signs in the airport had been more clear etc., etc. ad nauseum. 

But, when I got home I worked up a simple Cause Map that allowed me to escape my own private culture of blame and find a rather interesting action item to prevent this sort of failure in the future.

By following the same procedure that I would for a multi-million dollar issue, I was able to identify a simple solution that would prevent this particular incident from recurring.  I could not move the pizza place, I could not re-write the airport signs.  There were many things in the scenario that were clearly out of my control.  I could be more diligent about putting my cell phone back in my briefcase but that solution depended solely on “operator behavior” which is not completely reliable.  So, I, the management, decided to purchase a very distinctive case and lanyard for my cell phone.  This bright orange rubber case is a bit of an eye-sore according to my wife but, it certainly draws attention to itself.  It stands out against the dark console of a rental car and has helped me keep track of my cell phone on a daily basis.

We often see “Procedure not followed” as a finding in a Root Cause Analysis Investigation.  It is not uncommon that the investigation will stop at that point and the corrective action becomes; “Follow the Procedure”.  Taking the process to the next step is crucial.  Why was the procedure not followed?  How can we make it more likely that the procedure will be followed in the future?  Sometimes a very small adjustment can be the key to prevention.

Companies often reach very general causes in their investigations.  For example, the identified cause may be “Not paying attention”.

Just like the proverb, the devil is in the details, and the solutions are there too. Root cause analysis is an investigation approach for digging into what’s beneath the surface.

We provide free Excel templates and reference information on our website. If you are interested in learning more please go to our website at http://www.thinkreliability.com.  View the Cause Map I’ve worked up for this issue by clicking on “Download PDF” above.

Cheers, 

Loyd

This is the way the relationship between motivation and success is usually represented.  Motivated individuals succeed.  Managers need to focus on motivation first in order to lead their team to success.  I can think of multiple examples of teams working on a Safety Improvement Program, Reliability Effort, or Maintenance Turnaround/Shutdown plan and it always seemed that we were looking for a way to motivate our groups.

Motivation is, at best, elusive and difficult to conjure.  Think of a pep rally – lots of excitement sure, but focus? Not so much.  Motivation without a clear objective can lead a team to wander off scope.  As a leader or supervisor this was a constant challenge that I experienced.

Here is another interesting thought:

Success influences or can cause Motivation.  Teams that have a success can use that success as a catalyst for motivation.  The initial success serves as a compass or a “map” if you will toward team cohesion, focus and motivation.  At a very fundamental level I believe that everyone wants to be successful… some individuals may put more effort in than others.  Even the most negative of the “Grumblers” will embrace success.

How can we provide a catalyst?  One idea is success in solving problems.  Root Cause Analysis and more specifically Cause Mapping can provide a simple method to jump start a team.

Another key element is Positive Recognition of success.  And that means acknowledgement of the team!  As a Root Cause Analysis facilitator you must be sensitive to the fact that management may look to you as  the “Problem Solver”.  It is essential that you keep management focused on the team.  A simple e-mail posted in a common area can be “good enough”.  Prizes or rewards can actually trivialize the effort.

As a starting place or jumping off point pick an issue that is reoccurring and has attention.  The chronic issues can often times be more of a challenge for the Root Cause Analysis Facilitator.  Success in solving a problem that was widely thought to be a “necessary evil” or, “something we just have to work around” can be a huge catalyst for team motivation.

If you tackle a Chronic Issue and need assistance contact ThinkReliability.  We will help you and provide support.  For workshop attendees this is free of charge.  If you are just being introduced to Cause Mapping contact us anyway; we’ll give advice and get you started.

“Success precedes motivation, and once children see they can be successful, they will participate; thus, teachers must engineer success.”  from Classrooms that Work by Patricia Cunningham & Richard Allington (geared to 4^th & 5^th grade English reading).

Don’t forget some of the basic lessons we learned in grade school!

Cheers,

Loyd.

Checklists are wonderful tools when used effectively.  The checklist must be clear and simple to use.  AND the checklist must be used diligently.  Shortcutting the checklist invalidates the philosophy and effectiveness.

Pilots are an excellent example of the effectiveness of checklists.  There are more than four checklists that the cockpit crew goes through before any flight on a Boeing 737.  Ask any pilot if they use their checklist…  There is a saying;  “There are old pilots, and bold pilots.  But there are no old/bold pilots”. 

So here’s Loyd’s checklist issue.  My packing checklist for a workshop has over 108 items.  Some things range from putting a fresh package of post-it notes in my bag, pre-printing my boarding pass, or checking that I have aspirin. 

On a recent workshop that also involved my Scuba gear I left my wallet at home.  Between my two packing lists there are over 200 checklist items.  So here’s what did not go so well…  I left my wallet at home.  My wallet is not on my checklist…  It’s just too simple right?

The last time I remember leaving my wallet at home was in 2000 when my wife was 9 months pregnant.  Assuming I put my wallet in my pocket once per day that is approx. 3,000 tasks.  Failure rate of 1/3000 is not so bad, right?

In Root Cause Analysis we must also think about the impact to the goals.  In this particular case it almost impacted the diving portion of my trip…  (I was flying in a day before the workshop – going diving with decompression and air travel considerations can be tricky). 

The Cause Map outline would look something like this:

…not the end of the world.

Divers must be patient people and getting in a hurry or stressing out about a dive is not a good starting place.  The potential impact of missing a workshop was significantly reduced as the morning dive was scheduled for the day before the workshop.

This event did make me think about consequence of missing a workshop, including the hassle of rescheduling a workshop or adjusting the schedule from the client’s perspective.  The Customer Service impact could be significant.

Someone might look at the Cause Map above or hear me discuss this and say, “You were not paying attention… “ I would suggest that you NOT say this.

Such a statement will probably put people on the defensive.  Instead, identify the things that may have affected the person’s attention.  Then corrective actions can be explored.

So here’s the dilemma: do I add another item to the checklist for my wallet?

P.S.  This was a happy ending.  My system for traveling is to get to the airport well in advance of the flight.  My wife was able to bring my wallet and Loyd plus gear got onto the airplane.  …and the Dive was GREAT!  And all my gear had been packed correctly… 

Cheers,

Loyd

If customers choose to participate, the electrical utility will text page them to warn that the grid is reaching a peak capacity. The message will request that the customer please turn off all possible devices and turn up the thermostat 3 degrees.

The pitch from the local utility is that they can prevent building a new power plant over the next 5 years with cooperation from the customers. Now imagine the statement from the electrical utility. They are not promising to lower rates… they are merely asking for help in improving the environment. The Austin market is very sensitive to environmental concerns.

The participants will receive a text page when the plant is overloaded and are asked to reduce their electricity usage between 3 p.m. and 7 p.m. Delay running dishwashers and washers/dryers until outside of this four hour window.

In addition, the utility would send voluntary text pages to interested customers with a specific request to turn up thermostat on the air-conditioner 3 degrees on a maximum electrical load day. On this specific day in Austin the ambient temperature was 100F with the heat index at 108F. This is a true commitment from the customers! …and an indirect pay back in the form of less capital costs from the Electrical Provider.

This commercial and some discussion with my wife on our road trip (side note – not so economically friendly) resulted in me thinking about efficiency and shaving the tops off the peak loads.

 Cheers,

Loyd

Key things this person looks for:

Sloppy Sink?

Drab Walls?

Stuff on tables?

Decent quality tables?

What’s in the fridge?

We talk about housekeeping all the time with respect to the job site.  One benefit of housekeeping is that it shows caring and consistency.  There are articles written about Cause and Effect of Clutter.  Does clutter result in the behavior of the organization or does the organization behavior results in the clutter?  Perhaps this is a feedback loop (“death spiral”) similar to the Cause Map of the Financial Mess.

A company I was recently working with had adopted the 5D approach and one element was office cleanliness.  A picture was posted on the wall of the office before the process was implemented.  There was another picture of the same organized office as the process started.  Guess how easy it was to compare?  What kind of behavioral influences are now on that individual?

One personal observation is that clean machinery makes it easy to detect a problem.  Leon Hess was one of the last Oil Company Owners.  He insisted that the oil refinery be darn near spotless.  As an engineer for Hess Oil I thought this was a bit over the top and even wasteful since after all we worked with heavy, gunky, crude oil.  But now that I have more experience under my belt I see that by removing the clutter it becomes much easier to see the remaining hazards.  Even a casual observer can detect a flange leak or a hose strung out across a walkway.

The cleanliness also instilled pride when talking with peers in the industry.  Our attitudes became a match for the work environment.

(One of our instructors went thru a de-cluttering process a couple of years ago.  This can be a freedom and a burden at the same time.  If you commit make sure you commit fully.)

What does your break room say?

Cheers, Loyd.

The responses were fairly uniform.  The “bomb” was a clear and present danger, we all flinched -some of us outwardly and some of us inwardly- but we all clearly registered the threat.  He removed his visual aid (he picked up a water bottle for the demonstration) and seemed to wander off course.  In a somewhat irritating and off-handed manner he asked  how many of us had flown to the conference?  Most of us had.

“How did you feel sitting next to a device that has more energy than a small bomb?”  he asked.  Then, the connection was made.  Everyone paused and he began to talk about our perception of risk and how that impacts safety.

I do a lot of traveling and a lot of risk analysis in my work.  Our airline industry is safe and has the statistics to prove it.  I sleep quite soundly on my late night flights. 

After I returned from the conference I found a photo of an incident that occurred in flight that resulted in damage to an engine cowling of a medium size airliner.

Here’s what it looked like out the passenger window.

The aircraft depicted landed safely with no damage to the engine.  If you want more specifics about the engine cowling event get in touch with me.

The photo struck me because, with the cowling peeled away, the engine “looks” more risky/scary.  Perhaps if all engines were exposed like this one, we would be more conscious of the potential for explosion that exists on every flight. What is your perception of risk? 

Food for thought.

Cheers,

Loyd

This group of safety professionals was so frustrated with the term ‘Root Cause Analysis’ that I was asked to refer to the process as Causal Analysis instead.   I complied, and the facilitation went smoothly.  As technical people we perhaps miss some of the nuisances of language that can effect perception. 

There are multiple definitions of the word root; one definition is “origin”.  That definition has resulted in the miss-use of the term Root Cause Analysis.  Using the singular word ’cause’ also directs folks to searching for the ‘single thing’.  But nature leads us to a different definition.

At Think Reliability we see a root as a system; an incident has a system of causes. 

Where is the origin in the above photo?

Our process is not to identify one, simple and clean cause for an incident.  Rather, we are tasked with untangling and mapping what is often a tangled mass of causes that worked together.  Focusing on one ‘cause’ in a root system will not eradicate the issue any more effectively than pulling one strand from the tangled system of roots in the picture would kill the weed.

Causes Analysis does not roll off the tongue.  Using the phrase Root Cause Analysis is accurate but it may require an explanation.  As the investigators we have a responsibility to provide that explanation and educate.   Maybe next time, I’ll bring the picture.

Cheers,

Loyd.

In this situation a person had been distracted from the work task at hand and was injured.  It seemed pretty obvious.  The person was reaching out with a pole while standing on a cat walk.  While this individual was freeing a piece of debris from a conveyor system, the pole released suddenly and struck the person in the shoulder. 

This was a little confusing as they described this over the phone.  So, based on their verbal description, we drew a diagram on the screen as the team watched through a WebEx link.

The key discussion was that this was a smaller person who was not as physically strong as the other co-workers.  Imagine this argument… “If we just had a bigger person doing the job this (the incident) would have never happened.”   Empirical statements like this are tempting, but rarely true.

 As we worked together to create the diagram, something became clear. Due to the location of the platform, length of snag pole, and angle of the vibrating table it was nearly a requirement that the pole be fully extended with one hand.  This full extension would put any individual of any height or stature at risk.

We directed the conversation back to body position as opposed to the size of the person performing the task.  In order for the pole to strike the person’s shoulder the shoulder had to be in the line of fire.  Here’s where another diagram can be useful.

Adding more detail also allows for specific solutions.

The actual root cause analysis investigation had a lot more detail. But even this early on in the process, the discussion had shifted from blaming the physical attributes of the worker, to putting simple procedures in place to ensure that a similar incident could be avoided.  Clearly, the diagrams changed the discussion.  Most of the shapes used in the above diagrams are auto-shapes and lines built into Excel.  I cheated a bit and downloaded the stickman figure from the internet.

The diagram changes the discussion.

Great Risk Mitigation #2
During our planning for the party we recognized a hazard in our yard for children playing about. A bush-like plant has been in the process of dying for quite some time.  Cutting back the limb was a scheduled task that continued to be delayed and rescheduled.

Interesting how sometimes safety/hazard removal work tasks are easier to push back?

Here is a photo of the Hazard.

Even without doing a root cause analysis, I can tell this is not a pleasant falling hazard!

Needless to say time was running out in party preparation and while I made a plan with chainsaws and come-a-longs, Lisa implemented a very clever solution.

Moral – Temporary barriers can be clever but Do the Work in a Timely Manner.

As a post script: the hazard was removed after the party.

Cheers,

Loyd

A root cause analysis investigation we worked a while back involved the destruction of an 800hp DC Motor. The DC Motor had an eight pole design. Only four poles were connected. The motor operated fine at lower power settings. During sea trials of the ship the motor caught fire and filled the engine compartment with smoke and resulted in the ship coming to a full stop.

Total repair costs approached $900,000. Significant concern from the crew and leadership. The Captain was unhappy!

During the maintenance task wires had been disconnected. The project personnel were unaware that terminal wires would be lifted so no follow-up inspection was scheduled.

Can you see the difference between Port & Starboard field wiring?

The motor automatic shut-downs also did not function.

Corrective Actions
1. Simple wiring diagrams inside cover
2. Labels on Wire & Terminals
3. Terminal & Landing wire terminal style or size differences
4. Improvement of the shut down system; wiring up the temperature measurement devices in the rotor of the motor

Any one of these corrective actions, derived from the root cause analysis, can reduce the probability of motor damage/failure.