June 9, 2009 | Mark Paradies

Root Cause Analysis Tip: Reviewed for Unintended Consequences

Can a corrective action cause a bigger problem than the one it solves?

In TaprooT® Courses we teach people to use a technique called SMARTER.

SMARTER stands for:








This root cause analysis tip focusses on the Reviewed part of SMARTER.

Here’s the story.

Up in the state of New York, they had a good idea.

People sometimes fell asleep and ran off the road.

If they cut groves in the pavement outside the white line on the road, the “rumble” could wake up the snoozing drive.

So, they started cutting grooves all over.

This included a section of road frequented by cyclists.

One day while riding his bike home at night (low visibility), Richard Wilt, a New York police sergeant, came across a new set of rumble strips.

He was riding outside the white line to avoid the hazard of automobiles when he hit the rumble strips while coasting (not very fast) down a hill.

The groove – hidden in the dark – “grabbed” his tire and he flew over the handlebars … landing face first on the road.

Others have been injured in similar accidents when bikes hit rumble strips.

Which brings me make to a personal experience.

My daughter was riding a bike down a hill and didn’t notice the speed bump intended to cause cars to slow down.

When she hit it, it threw her off her bike.

She had a helmet on and received minor cuts and bruises. But it could have been worse.

So what does this have to do with root cause analysis?

Your corrective actions may have unintended consequences.

Nobody at the New York Department of Transportation thought about the dangers of rumble strips to bicycles.

How can you guard against this in your corrective actions?

Get them to be REVIEWED for unintended consequences by operators, mechanics, and others to help spot unintended consequences.

You might not spot every complication, but you will catch many problems before they are implemented.

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