Tag: failure analysis

Causal analysis is a surprisingly complex process that over the years has been subject to push and pulls from a wide variety of professional influences. When determining the actual cause of an accident or an incident, any number of stake holders would like to address the issue that “caused” the accident, whether to prevent a reoccurrence or, on the other side of the remedial spectrum, to punish the causal party.

 

In theory, there must be a cause for everything, but, in practice, finding the cause often involves a high level of judgment, and judgment is complicated and often deeply flawed. If judgment were to reside in one professional community, there is a possibility that some type of convergence on the determination of the cause of an incident could be developed. And once the cause is established, we can give that cause a name. It apparently is too simple to simply call it “the cause” of an incident, and that makes sense, since all too often there are multiple causes of an incident.  And because there can be multiple causes, different terms for causes have started to emerge.

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In the MAX1 study survey we included a few questions where we asked crews to tell us what their favorite Oily Water Separator brands are. We were very hesitant to include that question because there could be all types of weird bias and we would need a huge sample to makes sense of data where there could be as many as 40 brands and even more models mentioned.

The survey was very successful, but the “favorite brand of OWS” question was not very effective. We wanted to include that question because there is a real problem with brand specific customer feedback in OWS equipment.  Some OWS manufacturers may have great working relationships with certain ship owners, but, overall, shipowners simply buy what the shipyard deems a good deal, or they themselves specify a brand with little or no feedback from their crews.

 

The lack of feedback, on a systems design level, is very ineffective.  read more »

Technology failures are inevitable. The trick is to keep failures to a minimum and to keep failures in the “mostly harmless” category. Certain types of equipment can fail and the failure does not result in consequences that are too serious, while other types of equipment failures can make a mess of things almost right away. Ship’s steering gear undoubtedly belongs in the latter category, and, therefore, steering gear normally gets special attention in its design and construction. In our office we have had a spate of steering gear failure investigations lately and very interestingly they all seem to have different causes.

 

 

 

 

 

 

 

 

 

This is just a short list of recent steering gear failures that we were involved in:

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There is a Cold War (remember, that was before 1989) engineering joke that goes as follows:

 

The Russians had built a brand new huge airplane, and it was the pride of Russia, but they had a continuous problem with fatigue fracturing at the wing to fuselage connection.

 

They tried everything and it just kept fracturing. One day there was a goodwill tour of Americans that came to Russia and one of the tour members was a Boeing engineer.

 

One of the Russian aerospace engineers discovered this and during a quiet moment approached the Boeing engineer to see if he had any suggestions on the fracturing problem.

 

The Boeing engineer quickly came up with a solution. He said: “just drill tiny evenly spaced little holes right along the path where the fracture appears and the problem will go away.”

 

The Russian thought he was kidding, but they were desperate and decided to try it. Surprisingly it worked, the wing never fractured at the wing root again. Years later the Russian met the Boeing engineer again, and asked how he came up with that idea. The Boeing engineer told him it was easy, he just made the wing look like the perforations in Russian toilet paper, since that never tore at the perforations either.

 

But is there a kernel of truth in the joke?

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