RCA in historical disasters.

In my new company they run various courses for newbies and a wider lecture serious on quality related topics. Two of these have centred on historical disasters that either changed a related industry or was simply famous like the titanic sinking. In both lectures they looked at the root causes and investigation into those disasters.

These were very interesting because as quality professionals we can look deeper into them. I don't think general public look much further than captain of the Titanic speeding into an iceberg but if you go deeper there's been so much more that can and has informed maritime best practice.

So what historical disasters do you think have had the most profound effect on current practices? Do you find this interesting? Have you studied any of them?

I’ve always used engineering disasters as training material to demonstrate Problem Solving methods and for FMEA/risk assessment. It is essential to teaching the types of causes (immediate, conditions for failure, latent defects, systemic causes and causal mechanisms) and not to get fooled about them. It also teaches the value of avoiding hubris and “I am smarter than Mother Nature” disease as well as hwo to not blame the operator. Sooooo many lessons.

My go to disasters:
The flight of USAir 427. (See “The Mystery of Flight 427” by Bill Adair)
The Sioux City Crash United Airlines Flight 242 (fully referenced with pictures in my Resource on A Fresh Approach to Risk Assessment)
The Titanic (fully referenced with pictures, attached)
The Tacoma Narrows Bridge Collapse (Galloping Gertie) and The Hyatt Regency Walkway Collapse in Kansas City,
See “To Engineer is Human by Henry Petosky (Amazon) and How Engineers Lose Touch by Eugene Ferguson
The Boeing 737 Max MCAS Failure (See “How the Boeing 737 Max MCAS Disaster Looks to a Software Designer” by Gregory Travis

And so many others.
Remember that when your students balk and say that these case studies are old and no we are smarter: “those who forget the past are condemned to repeat it”

The Silver Bridge collapse over the Ohio River between Point Pleasant, WV and Gallipolis. OH, is a good case study because there is a lot of data available from the NTSB report on the collapse. It also holds the record for the largest number of fatalities from a bridge collapse. Structure Magazine has a good summary of that report, and NOVA aired a brief video that summarizes the cause. They ended up closing two additional bridges of the same/similar design as a result.

I once worked at a factory located about a mile from where this occurred. A lot of the company employees lost family members in the collapse.

@Bev D I like the causal systems approach (action plus condition) you used in the Titanic PDF.

@Miner Thank You. In 4 decades solving thousands of (complex) problems I have experienced that roughly 75% of the Problems were either a result of a condition for failure with a latent defect or action) or a standard interaction. Too often engineers think that the “root cause” is a linear binary thing.

As an example of current root cause practice (to contrast with historical approaches), I point people to te ATK report on Takata airbags:

As for historical cases, some early food adulteration cases are probably worth looking at:
...Not that the lessons learned have been absorbed (See 2008 Chinese milk scandal)

Thalidomide is another interesting story...

AllTheThings said:

As an example of current root cause practice (to contrast with historical approaches), I point people to te ATK report on Takata airbags:

https://www.nhtsa.gov/sites/nhtsa.gov/files/documents/orbital_atk_research_summary.pdf

Click to expand...

This should be a case study in ineffective corrective actions. The recall replaced aged inflators with new inflators. This did not correct the problem. All it did was reset the clock. At some point the replaced inflators will also fail due to the same issue. However, this time Takakta will no longer be around to foot the bill.

Alas, the two Space Shuttle Disasters and the Apollo 1? disaster...:-(

THERAC-25.

Miner said:

This should be a case study in ineffective corrective actions. The recall replaced aged inflators with new inflators. This did not correct the problem. All it did was reset the clock. At some point the replaced inflators will also fail due to the same issue. However, this time Takakta will no longer be around to foot the bill.

Click to expand...

Well said, in effect they are kicking the can down the road, an all too often scenario in the automotive arena :-(