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There was a problem with erosion of the Washington Monument. The Monuments rate of erosion had
increased. The initial cause was do to harsh chemicals used to clean off pigeon droppings. This being
an important monument for America a study was conducted to solve this problem. This is the story I
heard as recounted by Dr. Woods during her presentation at PSAM 10 in Seattle June 11,2010. I
apologize if any of the story is mis-communicated and any mistakes are mine.
As the study began the first thing that was discovered was the rate of erosion increased after harsh
cleaning chemicals began to be used. The analysts therefore concluded that the cleansers were the
problem. The cleansers were being used to combat a problem related to pigeon poop. Yup, need to
solve that problem. We cannot have one of our most powerful symbols covered in pigeon poop.
Doesnt say good things about us if we allowed that kind of mess. So, why were pigeons there? Well, it
turns out that pigeons like spiders (probably like I like hamburgers (I know I have eaten more than I
should have in the past) and spiders were now nesting in the Washington Monument? Well, Spiders
like gnats and gnats were all over the Washington Monument and only recently. It turns out that gnats
come out right at dusk and they are attracted to light. The Monument is bathed in light which were
turned on the same time each day not accounting for the seasons. So the solution to the whole
problem was to just turn the lights on later (well after dusk). No gnats therefore means no spiders and
therefore no pigeons.
Now this solutions is fantastic. You are saving electricity (very small amount) and there is no need to
use harsh cleansers. All in all an elegant solution to the problem. Of course, this is obvious after the
fact, but how could this solution be enacted by a single person. This has to be done with a few people
getting together at different levels to even see the problem. The cleaning crew isnt going to know
enough to solve this problem. The lightning person wont know- even if there is a lightning person
since the lights may have been automated.
My point is if something seems obvious after the fact- it isnt. You see this blame game going on
whenever you have an accident that seems obvious after the fact. When the details are effectively
communicated the problem can be solved and solved quickly- only once all the factors are known.
From the Titanic to now the British Petroleum oil spill- complex failures will have solutions, but only
after the fact until we can our attitudes and focus. I still refuse to believe that BP is solely to blame.
There are thousands of oil wells in the Gulf and around the world. The real problem was our human
nature to underestimate risk.
Improve the situation after determining root cause and most viable solution
Control the outcome by ensuring actions were effective and results are lasting
Triggers should also be established at the appropriate levels of loss. (For a link to a
Single Point Lesson for determining RCFA Triggers, click here.) Baseline metrics
need to be established and RCA findings need to be openly and frequently shared
with area owners and plant personnel. Use target condition metrics to provide the
business case to implement results. Quarterly metric reporting to senior
management is an excellent way to keep them engaged, giving them the tools they
need to be active and visible sponsors. For individual RCA reporting, I recommend
the A3 methodology, as shown below:
2.
residue off of a failure inner race can destroy potential evidence. To instill ownership
and understanding, employees must be involved in creating the RCA process..
Josh Rothenberg is a Life Cycle Engineering reliability subject matter expert (SME)
and a skilled Six Sigma Black Belt. Josh utilizes the tools learned in the tire
manufacturing, specialty chemical, and semi-conductor industries to help facilitate
change. With experience in CMMS, fixed/rotating equipment, logistics,
planning/scheduling, and a talent for fostering interpersonal relationships, Josh
brings a unique perspective to reliability centered maintenance that fosters the
growth and development of cross-functional teams. Josh can be reached
atjrothenberg@LCE.com.
2012 Life Cycle Engineering