Don’t Lose the Lesson Root Cause Analysis

During seminars, I always try to encourage people to devote a percentage of their time to case studies. “When you lose, don’t lose the lesson” I say. “Learn from your mistakes. But, don’t wait ’til you have had a tragedy to find a way to improve your own safety management controls. Learn from other’s mistakes.”

So pick up a newspaper from time to time, particularly when there has been a truck crash near you or in your industry, and read the article with a critical mind; thinking about root cause.

A lady in a car T-bones a school bus while she is talking on her cell phone. No one is hurt, but maybe this is a reminder to do some training on the consequences of distracted driving; with particular emphasis on decreasing cell phone use while operating CMVs. Maybe you even want to review your company’s policy on the practice.

In May 2013, A 51-year old man driving a garbage truck, talking on a cell phone, ignores an unmarked rail grade crossing, crossing in front of an oncoming train. The resulting derailment was caused by a driver who was talking on a cell phone using a hands-free device. Now, even though the driver was held to be responsible, there were also some changes made to the immediate surroundings and there was some serious discussion of who is responsible for maintaining infrastructure immediately adjacent to a rail-grade crossing. But we can all think about that driver using a hands-free device; do you have drivers who do this a bit too much? Maybe just a sobering word is all you can offer them. Personal cell phone use is a difficult thing to monitor, but you can try to share with your drivers some reasons they should consider cutting back, if they are on the phone constantly.

When I was a young man getting started in life, I joined the Army and soon found myself in the 82nd Airborne Division. I still read news items about paratroopers; possibly more than the average person would. In September 2013, there was a tragic parachute incident that took the life of a senior officer, and the Army conducted some really serious root-cause analysis: if you’d like to read about it, this is pretty sobering. It’s not about trucks but it’s about an organization learning from its mistakes:

I think, to some extent, all organizations do a pretty good job of learning from their mistakes. But how about learning from other people’s mistakes? I think we could all do a bit better; even my favorite organization: What if the officer who died on a routine parachute jump in September 2013 was in the French Army? Or the British Army? Do you think we would have made the same adjustments? Now let me ask another sobering question: What if this exact incident happened to a French staff officer in 2012, and the US Army ignored it, then a senior commander in the US Army suffered a similar fate in September 2013. You would say the Army failed to learn an important lesson, right?

So the next time there is an article about a truck crash in your local newspaper, or you hear about something on the radio, listen to the details and ask yourself “What caused that crash” or “Why are those people dead now?”. Sometimes you have to wait days, weeks, even a year or more, to find out what really went wrong. If it is a multiple fatality, the NTSB will eventually release an in-depth report. Look for lessons learned. Look for root cause. Think about what you can do to keep the same incident from occurring with one of your drivers.

Remember, “when you lose, don’t lose the lesson”.

But don’t wait until you experience a tragic loss; learn from other people’s mistakes and misfortune as well. It will accelerate your learning curve as an organization.

Here is a shortcut to some news coverage of the NTSB report: