Root Cause Analysis Information

A Serendipitous Solution

by Ksmiley on September 2, 2010

Investigating the recent massive oil spill in the Gulf of Mexico is a tall order.  There are many contributing causes and a multitude of creative solutions are going to be needed to restore the environment.

During any investigation of this magnitude, there are guaranteed to be a few surprises.  And the Deep Horizon oil spill is no exception.

Scientists have discovered a previously unknown type of oil-eating bacteria feasting on oil from the spill.

This microbe is unique from previously studied varieties because it doesn’t consume large quantities of oxygen along with the oil.  Oxygen consumption is a concern because oxygen is needed in the sea to support life.

This microbe also thrives in cold water temperatures associated with the deep ocean, which might explain why it hasn’t been seen before.  Some scientists are theorizing that the microbe adapted in the deep ocean to consume the oil that naturally seeped from the ocean floor.  Since the huge influx of oil to the water, the bacteria populations have exploded.

Scientists are in a disagreement over how much oil remains in the Gulf, but there is no doubt that less is better. 

This serendipitous solution is a welcome addition to the clean up efforts.  Obviously, there are many other solutions that will needed, but anything that safely reduces the overall amount of oil is a positive development.  Hopefully, with some additional research this microbe could be a potential solution to future incidents.

When performing an investigation, the unexpected sometimes happens.  The better understood the problem is, the easier it is to adapt to any new information. The Cause Mapping method of root cause analysis is an effective way to organize all information needed during an investigation.  Clearly understanding the causes that contribute to an incident will allow an organization to adapt as new information comes available and make sure that resources are used in the most efficient ways when implementing solutions.

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Washing Machine Failure

by Ksmiley on August 27, 2010

(This week, we are proud to announce a Cause Map by a guest blogger, Bill Graham.  Thanks, Bill!)

While completing household chores in the spring of 2010, a Housewife found her front load washing machine stopped with water standing in the clothing.  Inspection of the machine uncovered the washing machine’s drain pump had failed.  Because the washer is less than two years old, it was decided to attempt repair of the machine instead of replacing it.  A replacement pump was not locally available, so the family finds and orders a pump from an Internet dealer.  Delivery time for the pump is approximately one week, during which time the household laundry chore cannot be completed and some of the family’s favorite clothing cannot be worn because it is has not been laundered.  On receiving the new pump, Dad immediately removes the broken pump and finds, to his chagrin, a small, thin guitar pick in the suction of the old pump.  Upon discovery of the guitar pick, the family’s children report that the pick had been left in the pocket of the pants that where being washed at the time of the pump’s failure.  The new pump was installed and the laundry chore resumed for the household.

While most cause analysis programs would identify the guitar pick as the root cause to the washing machine’s failure, Cause Mapping unveils all of the event’s contributing factors and what most efficient / cost effective measures might be taken to avert a similar failure.  For example, if all the family’s children aspire to be guitar players, then a top load washer may better suit their lifestyle while also averting the same mishap.  Or, maybe the family should consider wearing pocket-less clothing.  Or, maybe all family members should assume bigger role in completing the household laundry chore.  Whichever solution is chosen, the impact of these and all contributing causes is easily understood when the event is Cause Mapped.

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Dissecting Safety Incidents: Using root cause analysis to reveal culture issues

August 19, 2010

The objective of a root cause analysis investigation is to prevention.  The causes of an incident are investigated, so that solutions can be developed and implemented, to reduce the risk of the same or a similar problem from occurring.  The process sounds easy, but in practice it can become more involved.  For example, what do [...]

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Spacewalk Delay for Ammonia Leak

August 13, 2010

Astronauts at the International Space Station ran into problems during a planned replacement of a broken ammonia cooling pump on August 7, 2010.  In order to replace the pump, four ammonia hoses and five electrical cables needed to be disconnected to remove the broken pump.  One of the hoses could not be removed because of [...]

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Therac-25 Radiation Overdoses

August 8, 2010

The Therac-25 is a radiation therapy machine used during the mid-80s.  It delivered two types of radiation beams, a low-power electron beam and a high-power x-ray.  This provided the economic advantage of delivering two kinds of therapeutic radiation with one machine.  From June 1985 to January 1987, the Therac-25 delivered massive radiation overdoses to 6 people around [...]

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Tackling Injuries in the NFL

July 29, 2010

It’s no secret that a lot of players get hurt in the National Football League (NFL).   But why does this happen?  Why do so many players get hurt?  And what may be a better question, is there a way to prevent injuries? This problem can be approached by performing a root cause analysis built as [...]

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Impure Injections Used

July 20, 2010

Research is been suspended at a prominent brain-imaging center associated with Columbia University.  Food and Drug Administration investigations found that the Kreitchman PET (positron emission tomography) Center has injected mental patients with drugs that contained potentially harmful impurities repeatedly over the past four years. Investigations by the lab determined that no patients were harmed from [...]

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Containment Cap Removed from Gulf Oil Leak

June 25, 2010

Last Wednesday, another set back occurred in the attempt to stem the flow of oil in the Gulf of Mexico from the a well head that was damaged when the Deepwater Horizon Oil Rig exploded on April 20 and sank 36 hours later . The containment cap used to siphon oil from the damaged well [...]

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Mine Explosion in Colombia

June 18, 2010

A coal mine explosion in Amaga, Colombia on June 16, 2010 has left at least 18 dead, 1 injured and at least 53 people unaccounted for, and presumed dead.  The deaths and injuries resulted from a fireball caused by an explosion.   Every explosion is caused by four factors: heat, fuel, oxygen and confinement.  In this [...]

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UPDATE: Convictions Result from Bhopal Tragedy

June 10, 2010

In a previous blog, we outlined the two theories of a 1984 tragedy in Bhopal that resulted in approximately 15,000 deaths. On Monday, June 7, 2010 (nearly 16 years after the incident) 7 former Union Carbide senior employees were convicted of “death by negligence” by an Indian court.  The sentence was two years in jail [...]

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