Root Cause Analysis Tip: Natural Disaster?
I’ve seen several investigations involving weather or natural disasters which just leave it at that. “Not much I can do about Mother Nature.” Take a look at this video:
Tornado Derails A Train
How do you deal with an incident that seems to be completely out of your control?
First of all, don’t do anything different. FOLLOW THE PROCESS! Start with a SnapCharT®, and see what questions need to be asked. You may find you have questions about:
– Training of the engineer on what to do in hazardous weather
– Ability of the engineer to see hazards
– Radio communications with operating base
– Type of cargo
– Load distribution
If you’re not sure what else you need to ask, you can use several tools:
1. Look ahead at the Root Cause Tree®. See if any of the 15 questions apply.
2. Try a Safeguards Analysis. Check to see if any of the 5 Safeguards questions we teach during TapRooT® courses apply in this case.
3. Don’t forget that the Dictionary® is checked full of great questions.
You may then come up with a few other things to check:
– Alertness of the engineer
– Engineer’s physical condition
– Availability of weather-related information
– Condition of the train cars, tracks, and signals
– Possibility of engineers being alerted by central base (signals, radio comms, computer alerts, etc)
– Training of the engineer on what to do when a derailment occurs
I’m not saying you’ll find problems in all of these areas. I am saying that you should use the TapRooT® System to help you figure out what to check. You should realize that, “Well, a tornado hit, and there is nothing that we can do about that” is not a get out of jail free card, allowing you to ignore the issue. There may still be some problems that management did have control over that could have prevented the accident, made it less likely, or made it less severe. Use TapRooT® to verify you have done everything reasonably expected to prevent the incident.