August 5, 2009 | Barb Carr

Root Cause Analysis Tip: How much can a “Dime” cost you? Cost Port Of Seattle $1M

Too Narrow Trench Could Cost Port Of Seattle $1M. “The Seattle Times reports Wednesday that a contractor at the port’s Terminal 30 near Safeco Field dug a trench for an electrical cable that was 0.02 of an inch too narrow. That meant the cable wouldn’t fit, and a new cable for the terminal’s giant cargo cranes had to be ordered for about $200,000.”

Now I can imagine that the plan went through a document and review transactional process…. which can be mapped out just perfectly on a SnapCharT® (Sequence of Events with an Incident). I wonder where the gap in the hazard and safeguards analysis will show up. I know, hazards are often thought of as uncontrolled safety of life energies like electricity. However, isn’t getting it wrong a hazard… think of the hazard of uncontrolled dimensions or stack up of tolerances. Think of it this way: if a bolt is just a little oversized and the bushing is just a little undersized and then I put a coating of corrosion control on it, it just won’t fit. Don’t laugh.. it took a long time to get that stuck rudder back off the aircraft with seized parts.

So for those of you who have taken our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training or 2-Day TapRooT® Incident Investigation and Root Cause Analysis courses pull out your workbooks and look up defining Casual Factors using Safeguard Analysis. You know the questions, just think about the Target and Hazard as it relates to Business or Work Processes. What safeguards are in place or which ones should have been in place? How did the product get too close to the customer? What made it worse when your client called you with a complaint?

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