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
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!
Now is the time to start planning for students and how they safely travel to/from home in the fall. Prior to the annual time change, Nov 7th, sunrise is at 7:39AM. This means that most high school and elementary school students will be walking or riding bicycles to school in the dark and during twilight, … More ACS Safety Note: Student Safety
Two vehicles were involved in a collision at a traffic signal intersection. An ACS engineer was tasked to examine the damage. One vehicle had damage to the passenger side bumper and the other had no damage of significance. The support brace to the damaged bumper collapsed. Occupants in the vehicles would not be injured unless … More From the Archives: Low Speed Impact