The best case scenario for the Root Cause Analysis (RCA) approach to safety is when used to investigate a “close call”. In our experience, these are infrequently reported. Most commonly, an RCA is conducted when a fatality/injury/other significant damage has occurred, making it a posteriori. It is a necessary step to be taken to prevent … More Organizational/Systemic Failure: Root Cause Analysis
In 1956, a handful of people died in the Arundel Park fire. “Several of the sample population indicated that when they entered the hall after observing the fire from outside the building, they warned their friends and suggested they leave but were laughed at, their warning apparently disregarded.” People have a difficult time interpreting indirect … More Organizational/Systemic Failure: Malignant/Dismissive Authority
As discussed in “The Search For Government Efficiency: From Hubris to Helplessness” by George W. Downs and Patrick D. Larkey, simply measuring the success of any particular organization is a challenge in of itself. For example, pages 74-87 discuss in detail the complexities of food inspection. How do you measure the success of the program … More Organizational Failure Measures
A critical report was released April 1985 by the National Highway Traffic Safety Administration focused on reducing braking distances of heavy vehicles. Among the findings it states, “Complete removal or deactivation of the front brakes, a practice which is common among some trucker users, obviously degrades the [braking] situation…” At issue is a rumored report … More Systemic Failure: The Ghost Report
In the previous post, I discussed OSHA relative to its reliability as a standard on which to judge the applicability of safety concepts. One way of looking at the field of safety is how to implement OSHA standards effectively, comprehensively, intelligently, and organically. With any type of measurement, whether quantitative with a ruler or qualitative … More Systemic Organizational Failure Root Cause: Safety as a Standard, Part 2
Systems Thinking generally is evaluating a larger thing by not just the function of individual parts but also how they interact as a whole. “Thing” can be just about anything; we are interested in the multi-dimensional interaction of people, equipment, government, environment, and money flow that comprises a single organization’s place in its market. These … More Systemic Organizational Failure Root Cause: Safety as a Standard, Part 1
Dr. Deming was instrumental in rebuilding Japan after WW2; his radical innovation in quality control methods is summed up in 14 qualitative management guidelines. Some of these are critical to addressing and preventing organizational failure but interestingly not all. Note that in the case of systemic failure, the failure is unique in spreading between teams/organizations. … More Organizational Failure Part 2: Crucial Deming Points
In the following weeks, we will be looking at various case studies of safety incidents that had an organizational failure as one of the root causes. Let’s look inside the Chernobyl incident. As discussed in this article, the following organizational issues occurred: RBMK reactor design flaw concealed from clients Reactor was scheduled to be tested … More Organizational Failure: Is it Systemic? Part 1
A water loss occurred at a residence when a water heater catastrophically failed. An ACS Engineer was hired to investigate. The drain valve to the water heater was removed by hand, not requiring tools. The failure was due to corrosion to the tank of the water heater. The corrosion extended upwards from the failure point … More From the Archives: Water Heater Failure
ACS Engineers, Elizabeth Jensen and Edward Jensen, share insights with a peer reviewed journal article into how to evaluate an operator’s manual based on our experience in engineering & safety!