Why, why, why, why, and why?

Source: Wikimedia Commons. This file is licensed under the Creative Commons Attribution 2.0 Generic license.

What’s new?

Since 23 March, a quarter-mile-long container ship, the Ever Given, has been stuck across the Suez Canal blocking all traffic in both directions.

What does it mean?

While news reports about this situation are mostly focusing on the efforts to move the ship and on the possible consequences for world shipping (do we need another reminder of the risks of long supply chains?), potential causes that have been mentioned include strong winds and a loss of steering power on the ship. Another report said that mechanical or engine failure had been ruled out and that the ship had been involved in an accident involving high winds in Germany in 2019.

What does it mean for you?

In Fall 2006, I was teaching, as I did each fall, an introduction to industrial engineering course at Colorado State University-Pueblo. My goal in that course was to help students get the big picture of industrial engineering, including that industrial engineers tend to blame the system, not the individual person, when mistakes and accidents occur. I told the class that initial reports of accidents often cite operator error as the cause, but that later reports often uncover deeper, systemic causes.

The next week, tragically, in Lexington KY,  a small jet took the wrong runway for takeoff, overran the too short runway and all but one of the 50 people aboard died; in an early news article, the cause was cited as operator error by the pilot for taking the wrong runway. As the class and I watched the evolving story over the semester, it emerged that the airport was undergoing construction and runway entrances had changed the week before; that, contrary to FAA guidance, only one controller was in the tower and he had turned to perform administrative tasks; that, again contrary to FAA guidance, the controller had been given multiple responsibilities; that small commuter planes were not required, as larger jets were, to have an onboard system that checks for the correct runway; and that other factors may have contributed to the crash. While it is clear that the pilot and copilot missed cues that they were on the wrong runway and engaged in irrelevant conversation while taxiing, the FAA took several actions as a result of the crash to improve the systems for ensuring use of the correct runway.

In writing this blog post, I found a 2019 analysis of the crash that stated that some of the lights on the correct runway were not working and that Comair practice did not include comparing the “heading bug” and the actual heading on the display.  That article stated: “Because it’s impossible to expect a pilot to never make a mistake, redundant systems exist to ensure that mistakes are caught and corrected quickly.” That article also states: “The nuance of the situation unfortunately was lost on many. The media largely blamed the pilots without recognizing that mistakes are never made in a vacuum.”

Tools exist to analyze systems for risks before accidents occur and to analyze causes after accidents. For example, my local Boys & Girls Clubs (I sit on their Board) recently instituted procedures for recording and analyzing mistakes that might have resulted in an issue concerning safety of club members, whether or not something bad happened. Kid safety is a strong priority of the Boys & Girls Clubs of America.

In my experience as an engineer, good engineers are obsessed with preventing mistakes and accidents, in a strangely matter-of-fact way. On a visit to a manufacturing plant years ago, my small group had gotten a thorough safety briefing and were outfitted in hard hats, safety glasses, steel toed shoes, orange vests, and more. As we left the briefing room to start the tour, we descended an external staircase. The engineer leading our group turned around to make sure that each of us was using the handrail on the stairs. I smiled.

About 12% of world trade by volume“ goes through the Suez Canal. This episode has resulted in no loss of life or pollution, but the design of a system to keep the Canal open is vital not just to Egypt but to the world. An article by Captain George Livingstone calls attention to the systemic issues created by the ever increasing size of container ships.

Every accident or near miss should be analyzed and systemic improvements should be generated and considered to prevent future occurrences. Another industrial engineering principle is that workers work in the system; managers work on the system.

Where can you learn more?

Techniques for analyzing risk and discovering the root cause of errors include: FMEA,  mistake proofing, and the 5 Whys. The 2015 version of ISO 9000 certification focuses to a great extent on risk management.  

The fascinating book The Box by Marc Levinson describes the development of the shipping container and the changes that were required to the entire shipping system.

This work is licensed under a Creative Commons Attribution 4.0 International License.

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