Root Cause Analysis Instructor Lead Blog

Pull Lessons Learned From Your People

July 7, 2009

The intent of lessons learned is to review a particular situation and provide specifics on what to do and not to do the next time.  Lessons learned are written within companies to share what went well and what went wrong.  How the lessons learned are documented and distributed can affect their success.
In the particular case [...]

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Hazards lurk in my own backyard

June 24, 2009

Great Family Idea #1
My wife Lisa is an amazing problem solver. We recently had dilemmas of financing three separate birthday parties for our children. Lisa decided that from now on we would have One Un-Birthday party for everyone! One big party and we scheduled it for the Friday before the last day of school.
Great Risk Mitigation #2
During [...]

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Don’t Stop at “Procedure Not Followed”

June 22, 2009

Over the course of two days, a U.S. airline placed an unaccompanied minor on the wrong flight on two different occasions. On June 13th, a child flying alone and under the supervision of the airline was scheduled to fly from Houston to Charlotte. Instead, she ended up in Fayetteville. One day later, a second occurrence [...]

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Wiring Error Costs a Motor

June 17, 2009

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 [...]

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Investigation of Air France Flight 447

June 12, 2009

The investigation into the causes of the crash of Air France Flight 447 is still in its earliest phases. This investigation is especially complicated because almost all of the evidence is spread across (and under) one of the more inaccessible areas of the Atlantic Ocean. Despite this lack of evidence, people have begun to work [...]

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Possible Unintended Consequences of Hazard Research

June 10, 2009

My last blog represented an observation of a hazardous condition in a major airport.
A person pointed out to me that while taking photos in a public place I could have raised suspicion as to the purpose. This person asked me: “What would you have done had security detained you for questioning?” Talk about an Unintended [...]

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Recognizing Hazards . . .Everywhere

June 4, 2009

For those of us in the business of keeping people safe and solving problems, there seem to be potential hazards everywhere.  I am continually struck by the number of these hazards I find in public places every day.  One recent encounter with potential risk led me to create a simple Cause Map.
I was making my [...]

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Nifty Excel Tips – Part 5 “Zooming In / Out”

June 4, 2009

The art of zooming on a spreadsheet is next in line for Excel Tips when building a Cause Map for a root cause analysis.  As you have probably noticed, once you start to add more detail to a cause map, you need to be able to zoom in and out on different sections of the [...]

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Taking responsibility is annoying; just blame catering

May 20, 2009

Earlier this evening I was on a regional jet flight from Houston to Nashville. Once we reached cruising altitude the flight attendant told us that catering had forgotten to stock the cups so she’d only be able to serve soft drinks in cans without ice and there would be no coffee or water available. It’s [...]

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Risk, Reliability and Root Cause Analysis

May 19, 2009

How a company communicates and prevents its problems is a reflection of its culture. Every problem really can be an opportunity to improve if the organization chooses to use the information. Like any other endeavor, if you don’t put the effort in, you don’t get the results. Companies that aren’t very good at investigating and [...]

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