146 workers were killed when a fire raced through the Triangle Company, which occupied the top three floors of a skyscraper in New York City. The workers were unable to escape the fire. We can examine this incident using a Cause Map, a visual form of root cause analysis, which allows us to diagram the cause-and-effect relationships that led to organizational issues – in this case, the death of 146 workers.
On March 25, 1911 at approximately 4:40 p.m., a fire began on the 8th floor of a New York City skyscraper (one of three floors housing the Triangle Waist Company). Although it’s not clear what sparked the fire (cigarettes and sewing machine engines are likely heat sources), a large amount of accumulated scraps (last picked up in January) provided plenty of fuel. There were no sprinklers and the interior fire hose was not connected to a water source. The fire spread quickly and burned for approximately a half an hour before firefighters extinguished it.
During that half-hour, 146 workers, mostly young women, were killed. Nearly all of these workers were from the 9th floor of the building. Workers from the 8th and 10th floor were able to escape to the ground or roof using the stairs, but one of the access doors on the 9th floor was locked. This left only one set of stairs and elevators, which did rescue many but were overcrowded and the elevator machinery eventually failed due to heat. Many attempted to escape using the fire escape, which was not built for quick escape (in fact, experts determined it would take 3 hours to reach ground from the Triangle Company floors) and eventually collapsed due to the collective weight, killing those on it in the fall.
Many workers jumped from the 9th floor, but the force of the fall was too great for the fire nets, which mainly broke and the jumpers died.
People were horrified at the conditions in the factories that resulted in these deaths. In the following years, public outcry resulted in many workers’ rights improvements, including many advances in regulations regarding fire protection and working conditions. However, these types of issues continue in other countries that have not defined such requirements.
To view the Outline and Cause Map, please click “Download PDF” above. Or click here to read more
Flying into a small airport surrounded by mountains at night, in a thunderstorm, with virtually no support from ground equipment proved to be too difficult for even an experienced pilot.
All 113 passengers and crew on Air France Flight 117 were killed when the plane crashed into a hill near the airport in Point-à-Pitre, Guadeloupe on June 22, 1962. The crash occurred in the early morning hours, during a severe thunderstorm. We can examine the causes of this tragedy in a Cause Map, a visual form of root cause analysis that shows the cause-and-effect relationships that led to an incident such as this one. The VHF (very high frequency) omnidirectional range (VOR) indicator, which helps aircraft determine position and stay on course, at the airport in Guadeloupe was not functional. (It’s not clear if the crew of the Air France flight was aware of this, or how long the equipment had been broken.) The plane in question was a Boeing 707.
The safety goal was impacted because all people onboard the plane – passengers and crew – were killed. The plane (valued at $5.5 million) was completely destroyed. The lack of a working VOR, and the incorrect information provided by the Automatic direction finder (ADF) can be considered impacts to the customer service goal. Beginning with the impacted safety goal, we can ask “Why” questions to begin mapping cause-and-effect relationships. The passengers and crew were killed (and the plane destroyed) when the plane crashed into a hill.
The plane crashed into a hill because the airport was surrounded by mountains, and the plane strayed off the let down track, which it should have used for its approach to the airport. The pilot went off track because he was using a visual approach, probably due to the fact that the VOR was not providing data since it was not working. The pilot was unable to see the track due to low (10 km) visibility and since it was early morning (~4 a.m.). In addition, the plane received incorrect position indication from the ADF, which appeared to malfunction as a result of the severe thunderstorm in the area.
This incident resulted in concern from pilots of substandard landing conditions at certain airports. More care is now taken with take-off and landing during inclement weather, poor visibility, or conditions that result in landing with decreased equipment support.
To view the Outline and Cause Map, please click “Download PDF” above.
