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 type of incident 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!


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.

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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.

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Courses & Training, Equipment Reliability / Equifactor®, Human Performance, Investigations, Operational Excellence, Quality, Root Cause Analysis, Safety
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