King County Root Cause Analysis in Action

The A3 below is an awesome example of root cause analysis revealing unexpected reasons behind problems.

Central Base Graveyard Chief, Rusty Bergerson and his team observed a reoccurring problem of bent steering brackets. Bergerson’s team turned what could’ve become a chronic bracket replacement—”These brackets never work!”—into a root cause identification by going to the gemba and seeing what was actually happening.


Bergerson and his team approached this problem through the lens of the customer, in this case, the bus driver. Bergerson himself went to the “gemba” (the place where the actual work happens) and observed and talked with the drivers about adjusting the steering column.

What resulted is Bergerson’s improvement hypothesis: that if the operators were better instructed on how to use the steering column, there would be less damage to the brackets (resulting in less work for the mechanics), fewer yard delays, and fewer frustrations and workplace injuries for the drivers.

Bergerson worked across “silos”, involving Operations, Training, and Vehicle Maintenance to build buy-in and to better grasp the problem and to test countermeasures based on that hypothesis.

Bergerson and his team are in the process of testing the hypothesis now and will be for a few months, so we don’t expect results for a while. In a few months it will be nice to hear back about what they have learned from his experiment.

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