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Mistakes, Errors, Judgement And Fishbones


gogogusgus
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In Twist 1 , Keith talks about Mistakes being Effects not Causes, that you have to work your way back from the mistake.

 

Anybody have their own system for RCA (Root Cause Analysis)?

 

He also discussed Errors and Judgement as Timing issues. Gotta admit I'm not sure I understand the distinctions.

 

In my answers to the Candidate Coach question sheet item about one's accidents, I created the table attached.

 

Based on Twist 1 though, and my background as a former manufacturing factory foreman, I wonder if a Fishbone analysis might be informative for certain left-brains?

 

Justin

-----------------

ridicule, then oppose

(ps This of course occurred to me en route the dogpark)

 

Crash #

 

Date

 

(reverse cron)

 

Event

 

Description

 

Root Cause Analysis

 

Outcome

 

Lessons-Learned

 

post-22577-0-29279800-1322845118_thumb.png

Crash.doc

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I always jokingly refer to those as "fishikawa" diagrams. I've never seen them used at the track although it's certainly useful for clarifying one thoughts about a crash. I'll have to think about this; I've had 2 low sides this year and I'm not sure what happened. All I cam remember is just before thinking "this doesn't feel right"!

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I'm glad you brought this up, Justin. I'm a quality manager by trade and was just thinking about this very issue.

 

You could make a nice cause and effect diagram out of all the Survival Reactions from "Twist II." For example, tight on the bars: hard to steer, excessive fork dive on braking, hands going numb, hard to look into turns (shoulders and neck stiff too). If you did this and put in all your OWN effects, it might be very insightful.

 

I was also thinking about how you can have five riders going around the same turn, at the same speed, on almost the same line and the guy in the middle low sides. How the heck does THAT happen?

 

Mechanical Failure (not usually)

Line (but not when five riders, or you and your buddy, are on the same line)

Steering (as in steering input--but I never see our mythical middle rider jerk the bars and fall down)

Speed (too much lean could really mean too much speed)

Acceleration (too much throttle when leaned over gets lots of us in trouble)

Braking (I've seen over braking cause a spill)

 

It is good that you are using the tools AND digging deaper. If, for example, you say the problem is too much speed (too much lean angle on a bike with a center stand is kinda the same problem), then you use the Five Whys technique.

 

Why are you riding too fast?

Because I'm trying too hard.

Why are you trying too hard?

Because it's the last lap, I'm tired, I'm competitive ...

 

You get it.

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  • 4 weeks later...

Hah - fishikawa. Never seen that before...

 

I haven't ever had to go into such detail thinking about accidents, mine have all (when I say all I mean just 4) been low speed (under 40km/h) incidents on the road. After a bit of thinking and replaying the events in my mind I've always been able to realise the cause (and lock it in the memory banks so that I never do it again). Actually, I always immediately knew that it was because of some little stupid mistake I've made, but I keep thinking it over to make sure I don't miss anything else.

 

Hopefully you're comfortable that you've figured out the problem? Nothing worse than not having a clear idea of what caused a crash.

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