RCA in historical disasters.

ScottK · Tuesday at 10:50 AM

In my senior year of college I took a grad level course in Industrial Safety. The professor was an expert witness for train accidents. I learned a lot about root cause analysis from him.

ScottK · Tuesday at 10:59 AM

Bev D said:
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”

I focus more on industrial accidents since I've been a manufacturing guy since 1990...
-Triangle Shirtwaist Company
-Bhopal Disaster
-The Great Molasses Flood
-The Great Mill Disaster in Minneapolis

AllTheThings · Tuesday at 1:55 PM

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.

The industry response and fix was poor. They even had to recall non-desiccated recall replacement units. But the study was pretty well done. To Takata's credit, they did the bare minimum and change some manufacturing processes to better seal against humidity cycling, which was what caused the morphology changes in the inflators. But yeah, they should have stopped using ammonia nitrate entirely.

Miner · Tuesday at 2:14 PM

@AllTheThings I agree with you about the study into root cause(s). That was well done. My issue was with the recall replacements.

RCA in historical disasters.

ScottK

Not out of the crisis

ScottK

Not out of the crisis

AllTheThings

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Miner

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