Wednesday, May 21, 2008

Root Cause Analysis

The RMS Titanic steamed out of Southampton England en route to New York on April 10th of 1912. This luxury liner was billed to be practically unsinkable. It struck an iceberg at 11:40 PM April 14th and sank 2:40 later. 1,520 lives were lost. This wasn’t the largest loss of life in a maritime disaster, but the Titanic still captures our imagination to this day. In fact, a recent book is out discussing the cause of the sinking. The book, called “What really sank the titanic,” is based on research conducted on samples taken from the shipwreck. I provided an earlier look at this issue, discussing how initial problems evolved into a catastrophic loss of life.

In a different angle, I looked at the root cause of the sinking, and found that Dr. W. Edwards Deming was right, yet again, when he said, "The problem is at the top. Management is the problem."

I performed a root cause analysis on the Titanic's sinking. Using the 5-Why approach, here is what I found. There are two branches to explore, first, why did the Titanic strike an iceberg at all, and second, why did it sink from the collision? This Blog entry is about the first question.

· Why 1: Why did the Titanic hit an iceberg?
o Standard operating procedures at that time for ice fields: post watchman and carry on.

· Why 2: Why did the watchman see the iceberg too late? Conditions:
o “Flat calm,” cloudless sky, 31 F. Watchmen looked for the white foam of waves crashing on icebergs' bases. That night, there were no waves.
o Moonless night: difficult to see anything.
o Not ideal conditions to see icebergs, but was the Titanic not to travel in these flat seas?
o Yes, it should be able to steam in these conditions. Since we can’t control the conditions, let’s step back up and ask why the watchmen failed to see the berg until it was too late. Did the watchman have standard tools, like binoculars?

· Why 2/B No. Why didn’t the watchman have binoculars to see in poor conditions?
o He was told they didn’t have them by an officer, even though there were two pair in the bridge.

· Why 3: Why denied?
o The officer didn't know or didn't care enough to find out. In essence, this is poor communication.

· Why 4: Why poor communication?
o If we answer this, we know why the Titanic hit the iceberg: root cause was poor communication between the watchman and the officer.

It could have been that the officer didn't know or didn't care. Either way, we are getting to the root cause. Let's say the officer didn't know...

  • Why 5: why didn't the officer know about binoculars on the bridge?

  • Poor training, new ship, lack of leadership and awareness... these are the problems, as Deming said, "at the top."

So we see, it wasn't that the watchman did a poor job, it was that he was not supported by the management system. This failure led to the Titanic striking an iceberg on its maiden voyage. Next we'll ask why the ship, described as "practically unsinkable," sank so quickly once it hit.

1 comment:

Fred said...

I disagree with your conclusion to Why 3:
· Why 3: Why denied?
o The officer didn't know or didn't care enough to find out. In essence, this is poor communication.

I suspect the officer was more bound by inappropriate social structures: Officers need binoculars more than mere seamen simply because they are officers, and therefore take precedence.

Authority trumps utility - Dilbert-culture reveals the perception that is commonplace even in the less class-sensitive modern times.