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.

Titanic Mistake

This photo of the Titanic under construction comes from the NY Times article describing a recent discovery concerning the sinking of the great ship. The Titanic was designed to be unsinkable, yet it sunk on its maiden voyage. The discovery shows why the Titanic sunk from striking an iceberg, and why it sunk so quickly, taking so many with her.



In the article, reported by William J. Broad, research by Jennifer Hooper McCarty and others shows the cause of the disastrous sinking was faulty rivets located in the bow. A transition from iron rivets to steel rivets was underway in shipbuilding of the times, and steel was the newly preferred, stronger material. Steel rivets were used in the areas designers felt it was most needed, in the main hull, but not in the bow nor stern. Iron rivets were specified, and there were shortages. A lower grade iron rivet was used in the Titanic, as demonstrated in samples recovered from the ship. When compared to standard wrought iron, there is up to three times the inclusions, or trapped slag, in the iron. Inclusions make the steel weaker, providing fracture paths for failure propagation.



How could this be? This was a premium luxury liner of the time and there were cheap rivets? It is a story of a crisis with seeds in decisions far removed from the chilly arctic where the Titanic lays today. In an earlier post, I described a model for a crisis with an adverse outcome:

- An initial problem, often minor in isolation, that goes uncorrected
-A subsequent problem that compounds the effect of the initial problem
- An inept corrective effect
- Disbelief at the accelerating seriousness of the situation
- Generally, an attempt to hide the truth about what is going on while an attempt is made at remediation
- Sudden recognition that the situation is out of control or “in extremis”
- Finally, the ultimate disaster scenario involving significant loss of life, financial resources, or both, and ultimately, the recriminations.

* Initial problem: material shortages. There were three huge ships being built at the same time and materials and labor were in short supply. Iron rivets were substituted for steel and used in the bow.

* Subsequent problem compounding the initial one: the proper iron rivets were not ordered (due to a shortage?) and the ones received had inclusions, weakening them. They came from smaller forge shops not normally used by the shipbuilder.

* Corrective Effect: There was none that we know because the iron rivets were not tested and found to be weaker than required. The Board of Trade stopped inspecting iron rivets at the time, deciding they were a mature technology and the focus went to steel.

* Disbelief at the accelerating seriousness: this had to occur the night the Titanic hit an iceberg. Due to the weaker rivets, the Titanic literally fell apart at the seams in the bow, allowing water to rush in and sinking the ship faster than anyone could respond.

* The final disaster scenario: the sinking of the Titanic with all the loss of life and property associated with it.

Interestingly, denial and recriminations persist to this day. When asked about the research findings, the shipbuilder, "Harland and Wolff, after its long silence, now rejects the charge. 'There was nothing wrong with the materials,' Joris Minne, a company spokesman, said last week. Mr. Minne noted that one of the sister ships, the Olympic, sailed without incident for 24 years, until retirement. (The Britannic sank in 1916 after hitting a mine.)"

The Titanic rests at the bottom of the Atlantic, with six slits in its bow. The slits replace seams once held closed by iron rivets, and the slits stop where the steel rivets hold the seams together still.

Patterns of Crises

The direct translation of these Chinese characters, which mean crisis, is "an opportunity riding a dangerous wind." Although crises present opportunities, most crises are unwanted and we feel better off without.

In his book, Will Your Next Business Mistake Be Fatal? Avoiding a Chain of Mistakes that Can Destroy Your Organization, Robert E. Mittelstaedt, Jr. describes a pattern traced back from crises. Mittelstaedt finds that the pattern includes these components (and I quote, from the book):

"- An initial problem, often minor in isolation, that goes uncorrected
- A subsequent problem that compounds the effect of the initial problem
- An inept corrective effect
- Disbelief at the accelerating seriousness of the situation
- Generally, an attempt to hide the truth about what is going on while an attempt is made at remediation
- Sudden recognition that the situation is out of control or “in extremis” (In extremis is a Latin phrase meaning "in the furthest reaches" or "at the point of death".)
- Finally, the ultimate disaster scenario involving significant loss of life, financial resources, or both, and ultimately, the recriminations."

If this pattern seems familiar, it should, because most business problems that become crises follow this pattern. Also, the large crises our governments face can be traced back through the same pattern.

What to do, then, to avoid these crises? Clearly, the chain of escalation must be broken. The first component of the pattern is the initial problem. So many crises start out small, in a manageable scope, yet go unfixed. An effective method of problem detecting and corrective action nips these problems in the bud.

When the initial problem gets past the first wave of defence, an interacting problem often amplifies the first one. Now a real mess is brewing. If corrective action fails here, the next phase in escalation is when those responsible begin hiding the problem or downplaying its significance. This can be done through filtering information as it goes up the chain of command. A boss can work to avoid filtering by having several lines of communication to compare messages and validate what he or she is hearing. When there is a disconnect, one of the sources is either filtering information or out of touch. Regardless, this is when help is needed but somehow doesn't show up.

Next, the crisis erupts in some undeniable way. People ask, "how could this happen?" There is enough blame to go around and lessons are learned and spread throughout the organization, but the key question is, is there a system in place to root out problems in their infancy and solve them completely? If not, be ready for more "opportunities riding dangerous winds."

With years of problem solving and corrective action experience, The Flying Toolshed implements corrective action systems so crises may be avoided all together. We believe creating opportunities for our clients rather than having opportunities thrust upon them.

bob@flyingtoolshed.com

Imperiled Start Up

"Foolish consistency is the hobgoblin of small minds."
Ralph Waldo Emerson


I was in charge of a new plant start up -- a risky assignment since many launches went badly, and this was my first try at it. My responsibility was to take an empty shell of a building and populate it with machines and people, processes and systems, and generate profit.

This launch depended on implementing some unproven new technology, a red flag. The technology in question was elaborate mechanical tooling which deployed in a CNC machine to cut a precise spherical radius on the ID of a casting. To perform this feat, the CNC equipment loaded the casting, then the tool, in the shape of a cylinder with a slot cut out of the side, was inserted into the casting opening. The tool had an ingenious mechanical device to deploy the cutter from the slot using a spine-like grooved lever. The cutting was done at high speed (turning the tool), and at the end of the cycle, the tool was quickly stopped then the cutter was retracted using spring action, hiding the cutter away in the cylinder again, and the tool was pulled from the casting. Nice Idea!

We got the equipment in and set up. We hired great people. We did a lot of training. All the while, I kept hearing about broken cutters. This was troubling because it was unproven technology and the entire start up depended on success. Not only that, cutters cost over $100 each, so the budget was feeling the pain.

We talked to the experts at the toolmaker. They tried to fix the problem. They kept trying, but to no avail. Finally, after weeks and weeks of trying, it became clear that this start up was in peril.

I ordered autopsies of each broken cutter. We opened up some tools to see what was happening. The engineers were puzzled and befuddled. We were asked to start working on "Plan B," which would cost a lot in capital to retrofit our operation. Then I saw the key.

Each tool that had a broken cutter, when opened up, had several small retracting springs which had toppled in the deceleration. The centrifugal force caused the springs to fall over on their side, laying down and providing no force to retract the cutter.

A big shock-absorber spring, that's what we needed! Once we figured out how to place strong enough spring coaxial with the center line, the decelerating forces were overcome by better engineering. The funny thing was, it took a tremendous effort to convince the inventor of the technology to change it... even though the initial design was failing.

My take-away: be open to new ways of looking at things, especially if we invented something and the old way isn't working. When we invent something we are proud of, great! When improvements to that invention come along, better! Often new ideas come from the most unlikely sources, so have eyes and ears open, and minds prepared to accept the possibility of something better.

Please let me know about a time you saw an inventor learn how to improve their invention from an unlikely source...

For more information on the "imperiled start up": http://www.mmsonline.com/articles/069903.html