Customize Consent Preferences

We use cookies to help you navigate efficiently and perform certain functions. You will find detailed information about all cookies under each consent category below.

The cookies that are categorized as "Necessary" are stored on your browser as they are essential for enabling the basic functionalities of the site. ... 

Always Active

Necessary cookies are required to enable the basic features of this site, such as providing secure log-in or adjusting your consent preferences. These cookies do not store any personally identifiable data.

No cookies to display.

Functional cookies help perform certain functionalities like sharing the content of the website on social media platforms, collecting feedback, and other third-party features.

No cookies to display.

Analytical cookies are used to understand how visitors interact with the website. These cookies help provide information on metrics such as the number of visitors, bounce rate, traffic source, etc.

No cookies to display.

Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors.

No cookies to display.

Advertisement cookies are used to provide visitors with customized advertisements based on the pages you visited previously and to analyze the effectiveness of the ad campaigns.

No cookies to display.

August 15, 2023 | Mark Paradies

What Type of Incident Is This?

Train service problems

Equipment Reliability or Design or Safety or Quality?

CTV News reported on a problem with the commuter train service in Ottawa, Canada. HERE is a link to the article. The notice above is from the OC Transpo website about a partial return to service of the affected line.

The article says OC Transpo is performing a root cause analysis on the failure of a bearing on a train car hub. The failed bearing was discovered during a routine maintenance inspection.

A failed bearing makes this an equipment reliability type of incident … right?

But it seems that the equipment reliability issue may be related to the design of the hubs. Or maybe it was the design of the rails (made by a separate company). Thus, this makes this a design type of incident … right?

But the whole train line was shut down over safety concerns while the problem was being evaluated. The shutdown lasted over a month. The safety issue makes this a safety incident … right? (Think of it as a near-miss to a derailment or fire.)

Commuters who used the train had to make other arrangements while the train was out of service. They could drive, take an Uber, or try to connect on buses. All these were a hardship for the train’s customers. A hardship on customers is a quality incident … right?

So what incident type was this? Was it an equipment reliability, a safety, a design, or a quality incident? Maybe, it was all four!

Here is a short video about the problems…

Root Cause Analysis Is The Same

No matter what incident type this was – safety, quality, design, or equipment reliability – the root cause analysis should be the same. The root causes are probably related to human performance. Even the root causes of equipment reliability issues are usually human performance issues.

How do you find the root causes of quality, safety, or equipment reliability incidents? That’s easy!

EASY

TapRooT® Root Cause Analysis is the answer.

TapRooT® Root Cause Analysis has been used by industry leaders to find the root causes of safety, quality, design, and equipment reliability incidents for over 30 years. It has been used by many transit companies that provide light rail service. (See a couple of success stories HERE and HERE.) Plus, TapRooT® Root Cause Analysis meets all the required fundamentals of advanced root cause analysis.

Find Out More About Advanced Root Cause Analysis

The best way to learn about advanced root cause analysis is to attend a TapRooT® Root Cause Analysis Course. See the courses to consider HERE.

public TapRooT® course

You can CONTACT US to get a quote for a course at your site, or you can attend one of our public courses that are held all around the world. CLICK HERE for a list of our upcoming public courses.

TapRooT® Changing the Way the World Solves Problems
Categories
Courses & Training, Equipment Reliability / Equifactor®, Human Performance, Investigations, Operational Excellence, Quality, Root Cause Analysis, Safety
-->
Show Comments

Leave a Reply

Your email address will not be published. Required fields are marked *