August 2, 2007 | Mark Paradies

I-35W Bridge Collapse Proves Need for Instant Root Cause Analysis

Of course I’m saddened by the loss of life that occurred when an interstate bridge spanning the Mississippi River collapsed. But I can’t help thinking of the broader implications of this failure.

Bridgevideo3
Click for video of fallen bridge.

Fox News, CNN, MSNBC, and even the Weather Channel were talking about the tragic collapse. The TV talking heads we already starting to either guess, or ask their guests to guess, what the causes of the collapse were. In all the coverage I only saw one true bridge expert, who seemed credible, explain how metal fatigue (fatigue cracking) could lead to this type of failure. Most of the other anchors, on-scene reports, and experts babbled endlessly to fill the airtime.

These people obviously needed instant root cause analysis.

Our 24 hour news cycle can’t wait for real answers at to what happened and how a bridge could fail so dramatically and tragically. And our political system can’t wait until they start pointing fingers and placing blame.

A good example of this is the post Katrina coverage of the levee failures. Only recently has the information become available as to the long history of failures that caused that disaster. But the press coverage of that history – that includes legislative failures, compromises of public safety due to environmental lawsuits, and issues of project management by the Corps of Engineers – has been almost nonexistent. They couldn’t wait for a detailed analysis of the facts. Instead, they jumped on the blame train.

What can you learn from this disaster at this early stage? First, if you are responsible for investigations of major accidents at your company, you had better be ready to deal with the press. They won’t be willing to wait for a detailed root cause analysis and they will get “experts” on the air to explain what “might have gone wrong.” You need to express concern and genuine sadness (which should be easy because you will be concerned and genuinely saddened) and then explain what you will be doing to find the real root causes of the accident without jumping to premature conclusions.

Another lesson learned from this accident could be that incident investigators need to be prepared to start an investigation and find out what happened and how it happened as quickly as possible to provide real information to the press rather than pure speculation. However, you should always caution those who will listen that WHAT HAPPENED and HOW IT HAPPENED still is not the ROOT CAUSES of WHY IT HAPPENED! What and how are just the information you need to draw your SnapCharT®. Further detailed, systematic analysis is required to find root causes.

What if you are senior management? You need to restrain your initial urge to jump to conclusions and start placing blame. This will be difficult because if you don’t find someone else to blame, you may become the target for blame. The example of how wrong this initial urge to place blame can go was demonstrated by the BP Texas City Refinery explosion aftermath. The entire senior management chain – from the Plant Manager to the CEO of a major corporation left the company under a cloud – either voluntarily or by being fired – after they tried to place the blame for the accident on the operator and the supervisor involved in the incident.

Perhaps the most important lesson learned at this point is that the best way to avoid the whole post-accident blame cycle is to avoid the accident entirely.

After the accident, the need for previous fixes is always apparent. However, to have truly excellent, zero accident performance requires management that carefully listens to the voice of the facility expressed by the root cause analyses of incidents, near-misses, audits, and proactive improvement initiatives. That’s why senior management needs a through understanding of advanced root cause analysis and performance improvement – something that is almost completely missing from the senior ranks of government as well as the senior ranks of many companies. Perhaps this is why disasters – natural or man-made – continue to create a constant supply of tragic headlines.

Some readers may be thinking – “HOLD ON, OUR MANAGEMENT UNDERSTANDS ROOT CAUSE ANALYSIS!” I’m sorry … 5-Whys, fishbone diagram, and brainstorming won’t do the trick. They aren’t advanced root cause analysis. They won’t produce the results needed to accurately and consistently find the read root causes of problems.

Government decision making and major corporate failures are notoriously hard to analyze. Government decision makers who started the chain of events or kept it progressing may be long gone. And the way major disasters are analyzed – with “blue ribbon commissions” – seldom produce the permanent change needed to change dysfunctional organizations.  The commissions are appointed by the powers-that-be and are often full of people either interested in ensuring that their political party or organization isn’t blamed (or the other party or organization is blamed) or have an agenda that skews their analysis.

This leaves us with the sad reality that disasters will probably continue to produce headlines because the knowledge and systematic processes needed to stop accidents probably won’t be learned by a large enough fraction of the population to demand change from our elected officials and corporate leaders.

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