Root-Cause Analysis – Learning From Our Mistakes – Part 1

What does the Titanic and the Boston I-90 connector tunnel have in common? It seems that both had problems keeping things together and both suffered from lack of attention to quality assurance procedures.

These stories stand as testimonials to the importance of finding the true root-cause of a problem. We often act in haste to declare a problem addressed by implementing a patch to the problem even when the root-cause has not really been found.

Even when everyone involved has best of intentions, we still read about awful incidents that could have been avoided by following prescribed inspection procedures and resisting the temptation to favor cost cutting measures over safety concerns.

Let’s start with the Titanic…

Shipbuilders wondered for years why the Titanic sank so quickly. Almost a century after the tragic accident, we are learning more about the unresolved mystery thanks to root-cause analysis on the ship’s remains. A few weeks ago, I saw on the Colbert Show, a fun interview with Jennifer Hooper McCarty. Jennifer is a materials scientist who co-authored the book “What Really Sank the Titanic” with Timothy Foecke from NIST. Her Ph.D. thesis on recovered material from the RMS Titanic led to her conclusions that substandard rivets on the Titanic may have been to blame for the quicker than expected sinking of the ship. According to the builders of the Titanic, even in the worst possible accident at sea, the ship should have stayed afloat for two to three days.

It seems that in order to cut cost or to expedite launch, substandard rivets were used in certain areas. Rivets were in tight supply during that timeframe. Metallurgical testing of 48 rivets recovered from the Titanic showed higher corrosion than expected for the prescribed rivets. Design engineers placed the weaker rivets in areas expected to see less stress, such as the bow. Unfortunately, that is right where the Titanic scraped an iceberg. McCarty and Foecke believe that fewer compartments would have burst if the higher quality rivets had been used. It’s even possible that the Titanic could have limped its way into Halifax.

Dr. McCarty also found evidence of complacency. For instance, the Board of Trade gave up testing iron for shipbuilding in 1901 because it saw iron metallurgy as a mature field, unlike the burgeoning world of steel.

Hindsight is 20/20, but have we learned our lessons, are the iceberg scenarios now part of standard Failure Mode and Effects Analysis (FMEA) on new naval ships?

On July 10, 2006, there was a fatal accident on the Boston I-90 connector tunnel to Logan airport. I will share more about that story on Part 2 of this article because I find similarities in the lack of attention to specifications and proper inspection procedures.

Recently we heard that delays in fasteners were partly to blame for some of the delays of the Boeing 787 Dreamliner. Let’s hope that we have learned from the root-cause analysis of these prior historical events and we don’t rush into replacement decisions without thorough analysis.

References:

Article in New Your Times April 15^th

http://www.nytimes.com/2008/04/15/science/15titanic.html?_r=1&oref=slogin

Blog: Women in Science:  http://sciencewomen.blogspot.com/2008/05/jennifer-hooper-mccarty-on-colbert.html

Comments

[Anna Ashmore]

Nice Reading. Thanks.
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