1 Titanic Cause Mapping Problem(s) Problem Solving ...

1 Titanic SankANDANDW ater Filled HullIceberg PresentSteel Plates Buckled on HullOpening in HullShip Didn't Turn SufficientlyTitanic SankShip Hit IcebergTransporting PassengersBulkheads Not SealedShip Crossing AtlanticSpeed (18 knots)Size of RudderEarly arrival into New York CitySaw iceberg lateNo BinocularsStrength of HullANDANDANDANDS afety ImpactLoss of 1500 LivesTitanic SankShip Hit IcebergSafety ImpactLoss of 1500 LivesSolution:Change steel hull design, materialsInsufficient lifeboatsANDS olution:Add more lifeboatsSolution:Improve bow watch comm processSolution:Slow down with known icebergsNorth Atlantic CurrentCause MapStep 1 is the Definition of the Problem . It is written in an outline format so that it's easy to capture and easy to read.

2 The Problem is always defined by the specific impact to the organizaiton's overall goals - the deviation from the ideal state. TitanicStep 2 is the Analysis of the incident. The Cause -and-effect relationships are identified by asking "Why?" questions starting with the Goals that were impacted. While the Cause Map may start linearly, as more information is added the Cause Map expands to provide a detailed view of the entire Level Analysis (zoom out) Start as a simple 5-whysMore Detailed Analysis (zoom in) Expand to as much detail as necessary12 Step 3 is the selection of specific Action Items to prevent the issue from occurring. Many possible solutions may be considered, but the only the best solutions are selected for implementation.

3 Each action item in the Action Plan will have a specfic owner with a scheduled due ItemOwnerDue DateStatus1 Insufficient lifeboatsAdd more lifeboats2 Speed (18 knots)Slow down with known icebergs3 Saw iceberg lateImprove bow watch comm process4 Strength of SteelChange steel hull design, materialsProblemStep MappingWhat's the Problem ?Why did it happen?What will be done? Cause Mapping is a visual, systems-based approach that focuses on fundamental Cause -andeffect relationships supported with evidence. The three basic steps of Cause Mapping are shown Map1 Solutions23 Houston, TX Office 281-412-7766 Copyright ThinkReliability 2009 Jan 2009 v1 Strength of RivetsSolve Problems.

4 Prevent Solving Incident Investigation Root Cause AnalysisWhat Problem (s) Titanic sank, ship hit iceberg, weak rivetsWhenDate. TimeApril 14th, 1912 WherePhysical LocationNorth AtlanticProcess LocationPassengers UK to USImpact to the Overall GoalsSafety1500 FatalitiesVesselLost entire ship7,500,000$ BusinessLiabilities, business loss16,500,000$ Frequency1xProblem DefinitionVessel ImpactLost entire shi