June 19, 2006 | Mark Paradies

Monday Accident & Lessons Learned – SMARTER Corrective Actions and Reviews for Unintended Consequences

 Cnn 2006 Us 06 11 Humvee.Rollovers.Ap Story.Humvee.Afp.Gi

“I believe the up-armoring has caused more deaths than it has saved,” said Scott Badenoch, a former Delphi Corp. vehicle dynamics expert told the Dayton Daily News for Sunday editions.

That’s the quote from a CNN story on troop deaths in Humvees in Iraq.

Sometimes corrective actions can cause more problems than they cure. The story doesn’t say for sure that adding armor was a mistake – but it suggests that it might be.

The last R on SMARTER (a technique that we teach in our courses that helps people develop better corrective actions) stands for REVIEWED.

Part of reviewing a corrective actions is to have someone independent of the corrective action development team review the corrective action for unintended consequences.

Perhaps an independent review of the added rollover risk posed by armoring Humvees might have caught this problem before personnel were killed in increasing numbers of roll-over accidents and tens of millions of dollars were spent on armor that might actually increase the numbers of fatalities.

This is also an example of how reacting to a safety problem can cause unintended problems that might make safety worse.

It certainly makes one think that developing corrective actions to address problems is harder that one might think!

One more interesting point in the story…

Army spokesman John Boyce Jr. told The Associated Press on Sunday that the military takes the issue seriously and continues to provide soldiers with added training on the armored Humvee.

The Army also made safety upgrades to the vehicle, including improved seat restraint belts and a fire suppression system for the crew, he said.

Notice that the Army’s first response to a problem is …

TRAINING!

The corrective actions may or may not address the root causes of the roll-over problem. They certainly don’t address the potential problem that the Army may have made matters worse by adding armor in the first place. (How should the Army do better root cause analysis and corrective action development?)

If you would like to learn more about advanced root cause analysis and developing SMARTER corrective actions, I would suggest a 5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Course. For more information see:

http://www.taproot.com/courses.php?d=2

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Accidents
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