Cost for QD employees to rent an apartment in Chico, CA. $1,200/month. Please turn off your ad blocker in Quality Digest
Our landlords thank you.
Scott Paton
Published: Wednesday, November 11, 2009 - 05:00
During my sabbatical from writing this column this summer, I watched an interesting program on the National Geographic Channel’s “Mayday” series1. It serves as a terrific example of how a good root cause analysis can get to the heart of a seemingly complicated problem.
The show focused on the details of British Airways flight 5390, which left the U.K.’s Birmingham International Airport for Malaga, Spain, on June 10, 1990. About 13 minutes into the flight, the left windscreen blew out, sucking the pilot halfway out of the aircraft. (The pilot had unbuckled his shoulder harness after takeoff.) The pilot’s feet caught on the flight controls and a flight attendant who happened to be in the cockpit grabbed the pilot’s waist, keeping him from being completely sucked out of the aircraft. The pilot was bent backward over the top of the aircraft in a 500-mph freezing-cold slipstream with little oxygen.
Meanwhile, the aircraft was diving uncontrollably through some of the world’s busiest airspace. The cabin had filled with condensation and debris was flying everywhere. Fortunately, after a few minutes, the co-pilot was able to regain control of the aircraft, contact air traffic control, and land the plane safely about 20 minutes later in Southampton. Miraculously, the pilot survived the incident with relatively minor injuries. The flight attendant who held onto the pilot also suffered minor injuries. No one else onboard the aircraft was injured.
This is a fascinating story with a happy ending. It makes for gripping television, but the most interesting part of the incident for me wasn’t the accident; it was the subsequent investigation into its cause—the root cause analysis.
The investigation into the accident focused on why the windscreen had blown out of the cockpit. This aircraft, a BAC-111, had an unusual design in that the windscreen was attached to the outside of the aircraft with 90 retention bolts. Most other aircraft have their windscreens attached to the inside of the cockpit, which prevents them from being sucked out of the aircraft. But, hundreds of other BAC-111s had the same design and their windscreens had not failed. The investigators soon discovered that the windscreen had been replaced 27 hours before the flight. Naturally, they turned their attention to the shift maintenance manager who had replaced the windscreen.
Instead of walking in and asking the shift maintenance manager what he had done wrong, the investigators took a different approach. They brought a psychologist with them to aid in their interview. They didn’t accuse or fix blame. They made him part of the investigation to determine the cause. They asked him what he had done on the day he had replaced the windscreen and why he thought it had failed. This approach put him at ease and led the team to discover exactly what had transpired.
The maintenance manager revealed that rather than check the part specifications on the bolts, he simply removed them, walked to the parts crib, and grabbed bolts that looked like the ones he had removed. Incredibly, the parts manager told him that he had grabbed the wrong bolts, but the maintenance manager ignored his advice.
The investigation team discovered that 84 of the 90 windscreen retention bolts were 0.026 inches too small in diameter, while the remaining six were 0.1 inches too short.
The team also discovered that the shift maintenance manager had some good reasons for doing what he did: the maintenance documents were located across the airport from where the maintenance work was being done. The previous installation of the windscreen had also been done incorrectly, so the bolts that the maintenance manager replaced were also the wrong size. There was no one available to verify that he had done his work correctly with the proper parts. In addition, he was working alone very early in the morning in a dark aircraft hanger.
Undoubtedly, the team would have discovered this information without the maintenance manager’s cooperation, but because of their nonconfrontational approach and by making the maintenance manager a part of the investigation, they got to the root cause very quickly.
How many times do we affix blame first when doing root cause analysis? Sure we may find out why the problem occurred but are we overlooking additional underlying causes and creating additional problems because employees are afraid to tell us the whole story?
Using your heart just might help you get to the heart of the matter.
Notes:
1. Originally produced in Canada as “Mayday -- Air Disaster” and in the United States as “Air Emergency,” episode “Blow Out” aired Sept. 14, 2004. http://en.allexperts.com/e/a/ai/air_crash_investigation.htm
Quality Digest does not charge readers for its content. We believe that industry news is important for you to do your job, and Quality Digest supports businesses of all types. However, someone has to pay for this content. And that’s where advertising comes in. Most people consider ads a nuisance, but they do serve a useful function besides allowing media companies to stay afloat. They keep you aware of new products and services relevant to your industry. All ads in Quality Digest apply directly to products and services that most of our readers need. You won’t see automobile or health supplement ads. So please consider turning off your ad blocker for our site. Thanks, Scott Paton is the president and CEO of Certus Professional Certification and the president of Paton Professional. He’s the former editor and publisher of Quality Digest, and now serves as editor at large. The Heart of the Matter
Sucking blame out of root cause analysis
Our PROMISE: Quality Digest only displays static ads that never overlay or cover up content. They never get in your way. They are there for you to read, or not.
Quality Digest Discuss
About The Author
Scott Paton
© 2023 Quality Digest. Copyright on content held by Quality Digest or by individual authors. Contact Quality Digest for reprint information.
“Quality Digest" is a trademark owned by Quality Circle Institute, Inc.
Comments
Look at the Process First
Scott,
Excellent article....and a very interesting story.
Sandra Gauvin
http://CurrentQuality.com.