Page 2 - Desert Wings 5-29-15

Desert Wings Commentary
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Getting to the roots of the matter
by Larry Kennedy
412th TW Ground Safety chief
Spring has sprung!
Coming recently from the East Coast, I was full of desire
to get out and see what damage the long and severe winter
caused. Cleaning and raking, picking up broken limbs and the
normal debris that winter brings. And then the normal spring
ritual of getting the yard and garden ready by trimming, prun- might be, tie into a safety theme?
ing, planting and weeding. Plus, I needed to get the property
ready to sell before my move out West.
On my long list of things to accomplish was the removal
of a network of viny weeds that had overgrown the back of
the yard and strangled out anything in their reach. This was
the perfect time to get at the root cause of my years-long
battle with this persistent tangle of weeds. The soil was ex-
tremely soft after thawing from the deep winter freeze and it
“shouldn’t” be too hard to pull them out.
Knowing that this would be a battle, so to speak, I as-
sembled my war gear: gloves, hoe, rake and shovel and pro-
ceeded to remove the vines, roots and all. You might describe
it as my “backyard mechanic” root- cause investigation and
analysis. How deep did these roots go? Where did they all
come from? I had put it off for years, but this time I would
get to the bottom of and remove the cause of the problem
for good.
I immediately relearned a lesson that I had learned several
years ago—removing this type of root was extremely labor
intensive and was probably why I had ignored the problem
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a shovel to dig them up. Some were so thick I needed ad-
ditional tools like a saw and axe to remove them.
I also discovered you need patience, lots and lots of pa-
tience.
There was not just a single root to uncover and remove;
there was a tangled web of wiry roots. You would be amazed
at the number of roots, how many were hidden, and the need
to slow down and rake the ground carefully to spot them be-
cause otherwise they would re-sprout. I’m not sure you can
ever get to the point where every single root is eradicated.
Being curious helped in rooting out the problem.
You’d grab a vine and begin pulling and with the ground
being so mushy the vine’s roots would rip through the earth
for several feet, in some cases going off in directions and
for some lengths. You can’t imagine how far some of the
roots traveled and you would be surprised by the invisible,
underground complex expanse of roots some plants have.
OK, now how does this particular situation, whatever it
It didn’t take long for my digging about in the backyard for
me to put two and two together and come up with this idea;
this is a sort of basic root cause analysis.
Over the years I’ve developed lesson plans and taught root
cause analysis, read about it, talked to safety professionals
and managers about it, and this I know: getting at the true
roots of a safety problem, incident, accident or mishap, is not
a simple nor is it a quick task.
Sure, due to time and mission needs, the investigator may
EHOHGWR¿QGDTXLFNDQGHDV\FDXVH in my effort to clear out the vines—it takes time, effort and
And if non—safety professionals are required to investi-
gate an incident, such as supervisors, there is the tendency to
not look too hard, not to dig hard or deep, not to be patient or
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put the due diligence into the effort because it detracts from
the mission/project and time and money is short. And if you
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individuals …” Oh, there wasn’t enough training or training
wasn’t adequate, personnel are taking shortcuts and not fol-
lowing standards or instructions ...
“Supervisors need to apply discipline here.” Often the
analysis doesn’t trace the root causes back to origins because
investigators don’t want to go there, such as highlighting
decisions made by management, or the lack of investments
in safety or safeguards by management. So their curiosity
doesn’t extend that far. It’s “safer” and more expedient to
play the short-sighted and biased blame game.
This allows some root causes to never be revealed. They’re
still down there, buried; they live for another day. Until they
spring up and cause another incident. This is what I learned
diligence to truly root out the causes of a problem.
Commander’s
Action Line
email: speak2cc@edwards.af.mil
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