I was skating with my daughters at an ice rink over the holiday break. We were seated in bleachers with the other skaters at the beginning of a Zamboni break to resurface the ice. Suddenly there was a loud pop. We watched a long water hose with a spigot and short pipe attached to the end whiz past the head of another employee who was helping to direct the driver. The hose used to fill the water tank on the Zamboni had not been disconnected before the driver began backing out. The hose stretched tight and broke the small pipe. The driver of the Zamboni was surprised and embarrassed with the crowd watching him. The other employees were all laughing. Their biggest concern was getting the water shut off that was spraying out of the wall.
It reminded me of a tragic incident in 1998 at Disneyland. A rope attached to a cleat on a dock was mistakenly used to help slow a sailing ship as it was docking in the park. A non-elastic rope, designed to break easily, had been replaced with a nylon rope which stretched to the point that it ripped the cleat out of the dock hitting one employee and two guests. One of the guests died from head injuries and his wife suffered permanent damage. There are more details to this incident, but with thousands of uneventful arrivals at the dock this one issue resulted in a fatality, a severe disfigurement and a multimillion dollar settlement. Root cause analysis is a tool for digging into the details of major incidents as well as the day-to-day issues.
From a safety standpoint the employees at the ice rink have been consistent when operating the Zamboni. Every time we’ve been skating, they’ve moved all skaters off the ice and closed the access gates to the rink before the backing out the Zamboni. Forgetting to disconnect the hose might seem like a minor issue, but if the employee was standing two feet to her left it could have caused a serious injury. The Zamboni is pulled onto the ice several times a day, 7 days a week. It’s a routine operation that’s done hundreds of times a month. But one time the hose was forgotten. A checklist could be posted directly on the wall right next to the Zamboni or adjacent to the start button. Defining the work process to include a review of the checklist each time doesn’t guarantee that an incident will never occur, but it can significantly reduce the likelihood. Can you hear the rink employees asking, “Do you really want me to step through the checklist every time I operate the Zamboni?” Yes, every time.
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