Plant Pathogen Threatens California Oak Trees

By Staci DeKunder

We are often overwhelmed by headlines addressing the latest disease outbreak facing the human population. In recent years, we have read with great concern about Ebola, measles, Avian flu, etc. Unfortunately, there is a similar outbreak facing oak trees in California. Sudden Oak Death is responsible for the death of over one million California oak and tanoak trees. And as it turns out, a microscopic pathogen called Phytophthora ramorum (P. ramorum) is behind the disease.

Matteo Garbelotto was one of the first two scientists to discover P. ramorum in 1995. Over 20 years later, scientists understand much more about how this tree killer operates and how it came in contact with the oaks.   P. ramorum thrive in humid environments, and can spread from plant to plant via wind, rain or with help from humans. Some plants are susceptible to the pathogen (like the California oak and the tanoak), and others are merely host carriers (California bay laurel, rhododendron and camellia). When a susceptible plant is infected, the pathogen attacks the tree’s bark, finding pathways into the tree. From there, it blocks the plants ability to circulate water and nutrients. This results in a fast demise for the tree, with symptoms of brown leaves and sap leaking from the bark.   If the pathogen finds a ‘host ‘plant, the plant is not harmed, but the pathogen can easily be transmitted to a nearby susceptible plant.   This is an issue both in nurseries and in the forest.   A simple Process Map can be created to depict how the pathogen wreaks its havoc on the trees.

As with most situations, understanding the problem is an important step to identifying solutions. Prior to discovering the pathogen P. ramorum, scientists were baffled by the bleeding trees. They initially suspected insects, but could find no visible wounds or damage typical of insects. Creating a Cause Map can help analysis the cause-and-effect relationships that are responsible for an impact to the goals. Asking ‘why’ questions beginning with the affected goal helps us to learn about the causes of an event. In this case, the environmental goal was impacted by the death of millions of trees. The hard work of Garbelotto and his fellow scientists showed that the trees were dying because they were exposed to the pathogen P. ramorum AND the fact that the trees were susceptible to its affects. The plants were exposed to the pathogen because the pathogen was carried from nearby plants. This was due to the fact that there were infected plants were located close by AND the presence of a mode of transportation. This mode of transportation could have been wind, rain and / or human transport. The human transport could be a result of people accidentally moving infected plants or soil.   There are infected plants close by because certain plants act as a ‘breeding ground’ for the pathogen AND because the pathogen was accidentally imported to the United States via host plants via the ornamental plant trade in the 1980’s. (Click on “Download PDF” above to see a Process Map and Cause Map of this issue.)

Fortunately, there are several identified solutions that can help minimize the impact of this pathogen. Using the Cause Mapping process, these solutions can be tagged to the specific causes that they impact. Then, a table of solutions can be created so that the owners (and due dates if applicable) can be tracked.   Five solutions are shown on Cause Map to help save the oak trees including: federally regulating the movement of host plants, using caution when moving plants and soil in infected areas, removing some host plants in infected areas, a phosphite spray which can be applied to infected trees and a smartphone application that can help educate and expand the current understanding of infected areas.

Marauding Monkeys Lead to Electrical Outage in Kenya

By Angela Griffith

One monkey managed to cause an electrical outage for all of Kenya – 4.7 million households and businesses – for 15 minutes to more than 3 hours. In order to determine solutions to prevent this from happening again, a thorough analysis of the problem is necessary. We will look at this issue within a Cause Map, a visual form of root cause analysis.

The first step of any problem-solving method is to define the problem. In the Cause Mapping method, the problem is defined with respect to the organization’s goals. In this case, there were several goals that were impacted. If the organization has a goal of ensuring safety of animals, that goal is impacted due to the risk of a fatality or severe injury to the monkey. (In this case, the monkey was unharmed and was turned over to the wildlife service.) The loss of power to 4.7 million businesses and households is an impact to the customer service goal. The nationwide power outage, which lasted from 15 minutes to over 3 hours, is an impact to the production/ schedule goal. Damage to the transformer is an impact to the property goal, and the time required for response and repair is an impact to the labor/ time goal.

The second step of problem-solving is the analysis. Using the Cause Mapping method, cause-and-effect relationships are developed. One of the impacted goals is used as the first effect. Asking “Why” questions is one way to determine cause-and-effect relationships. However, there may be more than one cause required to produce an effect. In this example, the power outage resulted from a cascading effect on the country’s generators. This cascading effect was caused by the loss of a hydroelectric facility, which provides 20% of the country’s electricity, and the unreliability of the power grid, due to aging infrastructure. All of these causes were required for this scenario: had the country had a more reliable power grid or more facilities so that the country was not so dependent on one, the loss of the hydroelectric site would not have resulted in nationwide outage.

Continuing the analysis, the loss of the hydroelectric facility was caused by an overload when a key transformer at the site was tripped. According to the power company, the trip was caused by a monkey falling onto the transformer. (There is also photographic evidence showing a monkey in the area of the transformer.) In order for the monkey to fall onto the transformer, it had to be able to access the transformer. The monkey in this case is believed to have fallen off the roof. How this occurred is still unclear, because the facility is secured by an electric fence designed specifically for protection against “marauding wild animals”.

The last step of problem-solving is to determine solutions, based on the analysis of this problem. The utility says it is “looking at ways of further enhancing security” at all their power plants. Unfortunately, total protection against outages caused by animals is impossible. In the United States, animal-caused outages are believed to cause at least $18 billion in lost economy every year. Just this May, raccoons caused outages to 40,000 in Seattle and 5,600 in Colorado Springs. This year also saw outages caused by squirrels, snakes, starlings and geese. Other unusual outages include work on a transformer causing an outage with economic loss of $118 million in Arizona (see our blog on this subject) and a woman with a shovel who cut internet service to nearly all of Armenia (see our blog on this subject).

Because power outages due to animals and other issues can’t be completely eliminated, ensuring a robust power grid is important to minimize the impact from and duration of outages. Calls for improvements to the aging infrastructure in Kenya have resulted from this incident, but these kinds of solutions require not only the cooperation of the utilities, but the country as a whole.

To view the problem outline and Cause Map for this incident, please click on “Download PDF” above

How Did a Cold War Nuclear Bomb Go Missing?

By Staci Dekunder

Is there a nuclear bomb lost just a few miles off the coast of Savannah, Georgia? It seems that we will never know, but theories abound. While it is easy to get caught up in the narrative of these theories, it is interesting to look at the facts of what actually happened to piece together the causes leading up to the event. This analysis may not tell us if the bomb is still under the murky Wassaw Sound waters, but it can tell us something about how the event happened.

Around 2 am on February 5, 1958, a training exercise was conducted off the coast of Georgia. This was during the most frigid period of the Cold war, and training was underway to practice attacking specific targets in Russia. During this particular training mission, Major Howard Richardson was flying a B-47 bomber carrying a Mark 15, Mod 0 Hydrogen bomb containing 400 pounds of conventional explosives and some quantity of uranium.

The realistic training mission also included F-86 ‘enemy’ fighter jets. Unfortunately, one of those jets, piloted by Lt. Clarence Stewart, did not see the bomber on his radar and accidentally maneuvered directly into the B-47. The damage to both planes was extensive. The collision destroyed the fighter jet, and severely damaged the fuel tanks, engine, and control mechanisms of the bomber.   Fortunately, Stewart was able to safely eject from the fighter jet. Richardson had a very difficult quest ahead of him: to get himself and his co-pilot safely on the ground without detonating his payload in a heavily damaged aircraft. He flew to the closest airfield; however, the runway was under construction, making the landing even more precarious for the two crew members and for the local community that would have been affected had the bomb exploded upon landing. Faced with an impossible situation, Richardson returned to sea, dropped the bomb over the water, observed that no detonation took place, and returned to carefully land the damaged bomber.

The Navy searched for the bomb for over two months, but bad weather and poor visibility did not make the search easy. On April 16, 1958, the search was ended without finding the bomb. The hypothesis was that the bomb was buried beneath 10 – 15 feet of silt and mud. Since then, other searches by interested locals and the government have still not identified the location of the bomb.   In 2001, the Air Force released an assessment which suggests two interesting points. First, the bomb was never loaded with a ‘detonation capsule’, making the bomb incapable of a nuclear explosion. (Until this time, conventional wisdom suggested that the detonation capsule was included with the bomb.) Second, the report concluded that it would be more dangerous to try to move the bomb than to leave the bomb in its resting place.

While we may never learn the location of the bomb, we can learn from the incident itself. Using a Cause Map, we can document the causes and effects resulting in this incident, providing a visual root cause analysis. Beginning with several ‘why’ questions, we can create a cause-effect chain. In the simplest Cause Map, the safety goal was impacted as a result of the danger to the pilots and to the nearby communities as the result of a potential nuclear bomb explosion. This risk was caused by the bomb being jettisoned from the plane, which was a result of the collision between the fighter jet and the bomber. The planes collided due to the fact that they were performing a training mission to simulate a combat scenario.

More details are uncovered as this event is further broken down to include more information and to document the impact to other goals. The property goal is impacted through the loss of aircraft and the bomb. The bomb is missing because it was jettisoned from the bomber AND because it was never found during the search. The bomb was jettisoned because the pilot was worried that the bomb might break loose during landing. This was due to the fact that the planes collided. The planes collided due to the fact that the F-86 descended onto the top of the B-47 AND because they were in the midst of a training exercise. The fighter jet crashed into the bomber because the bomber was not on radar. The planes were performing an exercise because they were simulating bombing a Russian target, because it was the middle of the Cold War. The search was unsuccessful because the bomb is probably buried deep in the mud AND because the weather and visibility were bad during the search.

Finally, the ‘customer service’ goal is impacted by the fact that the residents in nearby communities are nervous about the potential danger of explosion/radiation exposure. This nervousness is caused by the fact that the bomb is still missing AND the fact that the bomb contained radioactive material, which was due to routine protocol at the time.

Evidence boxes are a helpful way to add information to the Cause Map that was discovered during the investigation. For example, an evidence box stating the evidence from the 2001 Air Force report that the bomb had no detonation capsule has been added to the Cause Map. A Cause Map is a useful tool to help separate the facts from the theories. Click on “Download PDF” above to see the full, detailed Cause Map.

Kansas City Interstate Overpass Closed Due to 20′ Crack

By Angela Griffith

A bridge engineer watching a crack (previously described as “tight”) under the Grand Boulevard bridge noticed it had extended to 20′ on May 6, 2016. He immediately ordered the bridge closed, requiring the rerouting of the more than 9,000 vehicles that use the bridge every day. Replacing the bridge is estimated to cost $5 million.

Luckily, due to the quick action of the engineer, there were no injuries or fatalities as could have occurred due to either the bridge catastrophically collapsing while in use, or for motorists on the Interstate below being struck by large chunks of concrete falling from the overpass.

The overpass failure can be addressed in a Cause Map, or visual root cause analysis. The process begins by capturing the what, when and where of the incident (a bridge failure May 6 in Kansas City) and the impacts to the goals. Because there was the potential for injuries, the safety goal is impacted. The re-routing of over 9,000 vehicles a day is an impact to the customer service goal. The closing of the bridge’s overpass/ sidewalks is an impact to the production goal, and the cost of replacing the bridge is an impact to the property/ labor goal.

By beginning with an impacted goal and asking ‘Why’ questions, cause-and-effect relationships that lay out the causes of an incident can be developed. In this case, the impacted goals are caused by the significant damage to the bridge, due to a rapidly spreading crack.

The failure of any material or object, including all or part of a bridge, results from the stress on that object from all sources overcoming the strength of the object. In this case the stress on the bridge was greater than the strength of the bridge. Stress on the bridge results from each pass of a vehicle over the life of the bridge. In this case, 9,300 vehicles a day transit the bridge, which has been in service since 1963.

Stress also results from large trucks traveling over the bridge. The engineers suspect this is what happened, possibly due to an apartment construction project near the bridge. Says Brian Kidwell, an assistant engineer for the Missouri Department of Transportation, “My hunch is a very heavy load went over it. It could have been a totally legal load.” A “hunch” by an experienced professional is included in the Cause Map as a potential cause. This is indicated with a “?” and requires more evidence.

Legal loads on bridges are based on the allowable stress for a bridge’s strength. However, the strength of the bridge can change over the years. It is likely that happened in this case. Previous damage has been noted on the bridge, which also required bracing last month to fix a sagging section. However, the bridge was deemed “adequate” in an inspection eight months ago. Any needed repairs may not have occurred – there’s never enough money for needed infrastructure improvements. It’s also possible that water entered the empty cylinders that make up the part of the span of the bridge (this is called a “sonovoid” design) and they could have filled with water and later frozen, causing damage that can’t be easily seen externally.

For now, more information will be required to determine what led to the bridge failure. At that point, bridges of similar design may face additional inspections, or be replaced on the long waiting list for repairs. For Kansas City, some are taking a broader – and bolder – view and are recommending the older section of the Interstate “loop” be removed altogether.

To view the Cause Map of the bridge failure, click on “Download PDF” above. Or, click here to learn.

Experts warn that vehicles are vulnerable to cyberattacks

By Kim Smiley 

By now, you have probably heard of the “internet of things” and the growing concern about the number of things potentially vulnerable to cyberattacks as more and more everyday objects are designed to connect to the internet.  According to a new report by the Government Accountability Office (GAO), cyberattacks on vehicles should be added to the list of potential cybersecurity concerns.  It’s easy to see how bad a situation could quickly become if a hacker was able to gain control of a vehicle, especially while it was being driven.

A Cause Map, a visual root cause analysis, can be built to analyze the issue of the potential for cyberattacks on vehicles.  The first step in the Cause Mapping process is to define the problem by filling out an Outline with basic background information as well as how the problem impacts the overall goals.  The Cause Map is then built by starting at one of the goals and asking “why” questions to visually lay out the cause-and-effect relationships. 

In this example, the safety goal would be impacted because of the potential for injuries and fatalities. Why is there this potential? There is the possibility of car crashes caused by cyberattack on cars. Continuing down this path, cyberattacks on cars could happen because most modern car designs include advanced electronics that connect to outside networks and these electronics could be hacked.  Additionally, most of the computer systems in a car are somehow connected so gaining access to one electronic system can give hackers a doorway to access other systems in the car.

Hackers can gain access to systems in the car via direct access to the vehicle (by plugging into the on-board diagnostic port or the CD player) or, a scenario that may be even more frightening, they may be able to gain access remotely through a wireless network.  Researchers have shown that it is possible to gain remote access to cars because many modern car designs connect to outside networks and cars in general have limited cybersecurity built into them. Why cars don’t have better cybersecurity built into them is a more difficult question to answer, but it appears that the potential need for better security hadn’t been identified.

As of right now, the concern over potential cyberattacks on cars is mostly a theoretical one.  There have been no reports about injuries caused by a car being attacked.  There have been cases of cars being hacked, such as at Texas Auto Center in 2010 when a disgruntled ex-employee caused cars to honk their horns at odd hours and disabled starters, but there are few (if any) reports of cyberattacks on moving vehicles.  However, the threat is concerning enough that government agencies are determining the best way to respond to it. The National Highway Traffic Safety Administration established a new division in 2012 to focus on vehicle electronics, which includes cybersecurity. Ideally, possible cyberattacks should be considered and appropriate cybersecurity should be included into designs as more and more complexity is added to the electronics in vehicles, and objects ranging from pace-makers to refrigerators are designed to connect to wireless networks.

Florida under attack by another invasive species

By Kim Smiley

Florida’s warm climate has made it an appealing home to many invasive species, such as Burmese pythons (see our previous blog) and giant African land snails.  Researchers fear another species, the Nile monitor lizard,  is also threatening native wildlife.  Nile monitor lizards are intimidating reptiles, growing up to 5 feet long, and they are not fussy about what they eat, consuming almost anything smaller than they are.  They will feed on mammals, birds, reptiles, amphibians, fish and eggs. There have even been reports of Nile monitor lizards making a meal out of pet cats.

This issue can be analyzed by building a Cause Map, a visual format for performing a root cause analysis.  A Cause Map visually lays out the cause-and-effect relationships that contribute to an issue so that they are easily understood.  The first step in building a Cause Map is to fill in an Outline to help define the problem.  Basic background information is recorded in the Outline in addition to how the problem impacts the overall goals.  To build a Cause Map, start at one of the impacted goals, start asking “why” questions and add the answers to the Cause Map. For this example, we will focus on the environmental goal.

Invasive Nile monitor lizards impact the environmental goal because they can have a negative impact on native wildlife.  Why? Monitor lizards eat a varied diet and there are permanent breeding populations of these lizards in Florida.  Why are there populations of Nile monitor lizards in Florida? They were introduced into the environment and the number of Nile monitor lizards in the wild quickly increased. (It’s a bit awkward to write out the “why” questions in this way, but click on “Download PDF” above to see how the Cause Map would visually lay out for this example.)

Nile monitor lizards are basically a perfect (or perfectly bad, depending on your point of view) invasive species.  They grow quickly and breed at an early age.  They lay many eggs at once, as many as 60 eggs in a single clutch. Their natural habitat is very similar to southern Florida and they have a tendency to wander over long distances so it isn’t surprising that they would quickly spread from where they were originally introduced into the wild.

Researchers don’t know exactly how Nile monitor lizards were first introduced into the wild, but it typically occurs when pets escape or are released.  Nile monitor lizards are sold as pets.  Often they are small when sold, but they quickly grow large and can be aggressive.  Owners may release their pets into the wild if they become tired of them or are unable to continue caring for the lizards.  It’s easy to see how a small pet lizard may seem like a good idea, but turn out to be a less than ideal roommate when they have grown into a large, active predatory adult lizard, complete with sharp claws and teeth.  Not to mention, the cost of feeding such a pet might be more than anticipated.

Researchers are still working on developing the best methods to control Nile monitor lizard populations in Florida.  (It is unlikely that Nile monitor lizards will ever be eradicated from Florida, but officials hope to control the numbers.)  Three permanent breeding populations of Nile monitor lizards have been identified, one of which is estimated to be hold over 1,000 lizards.

DNA testing has shown that there are actually two distinct species of Nile monitor lizards and all lizards tested in Florida have been determined to be the newly-named West African Nile monitor lizards. West African Nile monitor lizards aren’t likely to spread too far north in Florida and beyond because they aren’t adapted to cold weather.  The other species of Nile monitor lizards is native to a cooler part of Africa and could potentially spread to a wider area if ever introduced into the wild in the United States.

Bottom line: please don’t release any nonnative species anywhere (even goldfish – see our previous blog).  You may think you are doing the right thing for your pet, but invasive species can do massive damage to native wildlife.  Call a pet store or your local fish and wildlife service if you can no longer care for a pet.  You can also help by reporting sightings of nonnative species to your local fish and wildlife services.

Airplane Emergency Instructions: How do you make a work process clear?

By Angela Griffith

What’s wrong with the process above?

This process provides instructions on how to remove the over-wing exit door on an airplane during an emergency.  However, imagine performing this process in an actual emergency.  During the time you spend opening the door, there will probably be people crowded behind you, frantic to get off the plane.  Step 4 indicates that after the door is detached from the plane wall, you should turn around and set the door (which is about 4’ by 2’ and can weigh more than 50 pounds) on the seats behind you.  In most cases, this will be impossible.  This is why emergency exit doors open towards the outside; in an emergency, a crush against the door will make opening the door IN impossible.

Even if it would be possible to place the door on the seat in the emergency exit row, it would likely reduce the safety of passengers attempting to exit.  As discussed, the exit door is fairly large and heavy.  It is likely to be displaced while passengers are exiting the airplane and may end up falling on a passenger, or blocking the exit path.

However, when this process was tested in training, it probably worked fine.  Why? Because it wasn’t an actual emergency, and there probably weren’t a plane full of passengers that really wanted to get out.  This is just another reason that procedures need to be tested in as close to actual situations as possible.  At the very least, any scenario under which the process is to be performed should be replicated as nearly as possible.

Now take a look at this procedure:

It’s slightly better, not telling us to put the removed door on the seat behind us, but instead it doesn’t tell us what to do with the door. Keep in mind that the person performing this procedure’s “training” likely consisted of a 30-second conversation with a flight attendant and that in all probability, the first time he or she will perform the task is during an emergency situation. When testing a procedure, it’s also helpful to have someone perform the procedure who is not familiar with it, with instructions to do only what the procedure says. In this case, that person would end up removing the door . . . and then potentially attempting to climb out of the exit with the door in their hands. This is also not a safe or efficient method of emergency escape.
This procedure provides a much better description of what should be done with the door. The picture clearly indicates that the door should be thrown out of the plane, where it is far less likely to block the exit or cause passenger injury.

The first two procedures were presumably clear to the person who created them.  But had they been tested by people with a variety of experience levels (particularly important in this case, because people of various experience levels may be required to open the doors in an emergency), the steps that really weren’t so clear may have been brought to light.

Reviewing procedures with a fresh eye (or asking someone to perform the procedure under safe conditions based only upon the written procedure) may help to identify steps that aren’t clear to everyone, even if they were to the writer.  This can improve both the safety, and the effectiveness, of any procedure used in your organization.

8 Injured by Arresting Cable Failure on Aircraft Carrier

By Angela Griffith

An aircraft carrier is a pretty amazing thing. Essentially, it can launch planes from anywhere. But even though aircraft carriers are huge, they aren’t big enough for planes to take off or land in a normal method. The USS Dwight D. Eisenhower (CVN 69) has about 500′ for landing planes. In order for planes to be able to successfully land in that distance, it is equipped with an arresting wire system, which can stop a 54,000 lb. aircraft travelling 150 miles per hour in only two seconds and a 315′ landing area. This system consists of 4 arresting cables, which are made of wire rope coiled around hemp. These ropes are very thick and heavy and cause a significant risk to personnel safety if they are parted or detached.

This is what happened on March 18, 2016 while attempting to land an E-2C Hawkeye. An arresting cable came unhooked from the port side of the ship and struck a group of sailors on deck. At least 8 were injured, several of whom had to be airlifted off the ship for treatment. We will examine the details of this incident within a Cause Map, a visual form of root cause analysis.

The first step in any problem investigation is to define the problem. We capture the what, when, and where within a problem outline. Additionally, we capture the impacts to the goals. The injuries as well as the potential for death or even more serious injuries are impacts to the safety goal. Flight operations were shut down for two days, impacting both the mission and production/ schedule goal. The potential of the loss of or (serious damage to) the plane is an impact to the property goal. (In a testament to the skill of Navy pilots, the plane returned to Naval Station Norfolk without any crew injuries to the flight crew or significant damage to the plane.) The response and investigation are an impact to the labor goal. It’s also useful to capture the frequency of these types of incidents.   The Virginian-Pilot reports that there have been three arresting-gear related deaths and 12 major injuries since 1980.

The next step in the problem-solving process is to determine the cause-and-effect relationships that led to the impacted goals. Beginning with the safety goal, the injuries to the sailors resulted from being struck by an arresting cable. When a workplace injury results, it’s also important to capture the personal protective equipment (PPE) that may have impacted the magnitude of the injuries. In this case, all affected sailors were wearing appropriate PPE, including heavy-duty helmets, eye and ear protection. This is a cause of the injuries because had they NOT been wearing PPE, the injuries would have certainly been much more severe, or resulted in death.

The arresting cable struck the sailors because it came unhooked from the port side of the ship. The causes for the detachment of the cable have not been conclusively determined; however, a material failure results from a force on the material that is greater than the strength of the material. In this case the force on the arresting cable is from the landing plane. In this case, the pilot reported the plane “hit the cable all at once”, which could have provided more force than is typical. The strength of the cable and connection may have been impacted by age or use. However, arresting cables are designed to “catch” and slow planes at full power and are only used for a specific number of landings before being replaced.

Other impacted goals can be added to the Cause Map where appropriate (additional relationships may result). In this case, the potential damage to the plane resulted from the landing failure, which was caused by the detachment of the arresting cable AND because the arresting cable is needed to safely land a plane on an aircraft carrier.

The last step of the Cause Mapping process is to determine solutions to reduce the risk of the incident recurring. More investigation is needed to ensure that the cable and connection were correctly installed and maintained. If it is determined that there were issues with the connection and cable, the processes that lead to the errors will be improved. However, it is determined that the cable and connection met design criteria and the detachment resulted from the plane landing at an unusual angle, there may be no changes as a result of this investigation.

It seems unusual that an investigation that resulted in 8 injuries would result in no action items. However, solutions are based on achieving an appropriate level of risk. The acceptable level of risk in the military is necessarily higher than it is in most civilian workplaces in order to achieve desired missions. Returning to the frequency from the outline, these types of incidents are extremely rare. The US Navy currently has ten operational aircraft carrier (and an eleventh is on the way). These carriers launch thousands of planes each year yet over the last 36 years, there have been only 3 deaths and twelve major injuries associated with landing gear failures, performing a dangerous task in a dangerous environment. Additionally, in this case, PPE was successful in ensuring that all sailors survived and limiting injury to them.

To view the outline and Cause Map of this event, click on “Download PDF” above.

 

The Force Was NOT With Them!

By Jon Bernardi

A long time ago, in a galaxy far, far away, the Empire tried to use their fancy Death Star to keep the member systems in line. This plan did not work out very well, as Death Star One (DS-1) was not able to fulfill its mission of empowering galactic domination! DS-1 had travelled across the galaxy to quell the rebellion at the rebel base on Yavin 4, but did not count on the über-Force of the Rebel Alliance. The Empire did not realize the power of the good side of the Force as the rebels overcame all odds and were able to destroy DS-1. We can do an analysis of the incident to determine the system of causes for the destruction and show those causes visually in a Cause Map.

As much as the Emperor and his minions would not like to see this published, we begin by looking at how the Empire’s goals were impacted. We start by developing an outline of the incident. You might suspect that different factions within the Empire see this problem differently! Some don’t believe there is such a thing as “The Force” and place their faith in the power of the machine. Others use the Dark Side to exploit the mortal weaknesses of the players. The goals of the Empire are impacted in a number of ways: DS-1 is ultimately destroyed, with loss of life, and loss of a dominant-style weapon. The Rebel Alliance has gained a toe-hold against the Empire! We use the impact to the goals as the first effects of our cause-and-effect relationships and will use the disparate view of “the problem” to help us with the branches of the Cause Map.

We already know that DS-1 had planet-busting capabilities, as demonstrated convincingly at Alderaan, Princess Leia’s adopted planet. This may have led the Empire’s power structure to doubt the “Power of the Force” and put their trust in a technological titan, “The ultimate power in the universe!” Even after the plans for the station had been obtained by the Rebellion, the commander of DS-1 still disregarded any concern of vulnerability in his unsinkable marvel. In a remarkable display of hubris, the Empire allows the small band of rebels aboard the Millennium Falcon to escape with the stolen plans for DS-1. The Empire intends to follow them, find the rebel base, and wipe out the rebellion once and for all!

Another branch of the Cause Map follows the path of the stolen plans and the re-awakening of the Force on the planet Tatooine. As we analyze this section of the map, we can see the convergence of causes that led to the technical experts of the Rebel Alliance finally obtaining the plans for DS-1, analyzing them and discovering the dreaded “thermal exhaust port” – (guess even a DS has to have a tailpipe!).

Even a long time ago, we see causes in multiple areas coming together to form the overall picture of the incident. The plucky Rebellion, had THE FORCE with them!

Oil Leaked from shipwreck near Newfoundland

By Kim Smiley

On March 31, 2013, oil was reported in Notre Dame Bay, Newfoundland.  Officials traced the source of the oil back to a ship, the Manolis L, that sank in 1985 after running aground.  The Manolis L is estimated to have contained up to 462 tons of fuel and 60 tons of diesel when it sank and much of that oil is believed to still be contained within the vessel.  Officials are working to ensure the oil remains contained, but residents of nearby communities who rely on tourism and fishing are concerned about the potential for more oil to be released into the environment.

A Cause Map, a visual format for performing root cause analysis, can be built to better understand this issue.  There are three steps in the Cause Mapping process. The first step is to fill out an Outline with the basic background information along with listing how the problem impacts the goals.  There is also space on the Outline to note the frequency of the issue.  For this example, 2013 was the first time oil was reported to be leaking from this particular sunken ship, but there have been 700 at-risk sunken vessels identified in Canadian waters alone.  It’s worth noting this fact because the amount of resources a group is willing to use to address a problem may well depend on how often it is expected to occur.  One leaking sunken ship is a different problem than potentially having hundreds that may require action.

The second step is to perform the analysis by building the Cause Map.  A Cause Map is built by asking “why” questions and laying out the answers to visually show the cause-and-effect relationships.  Once the causes have been identified, the final step is to develop and implement solutions to reduce the risk of similar problems occurring in the future.  Click on “Download PDF” to view an Outline and intermediate level Cause Map for this problem.

In this case, the environmental goal is clearly impacted because oil was released into the environment.  Why? Oil leaked out of a sunken ship because a ship had sunk that contained a large quantity of oil and there were cracks in the hull.  The hull of this particular ship is thin by modern standards (only a half-inch) and it has been sitting in sea water for the last 30 years.  A large storm hit the region right before oil was first reported and it is believed that the hull (already potentially weakened by corrosion) was damaged during the storm.  The Coast Guard identified two large cracks in the ship that were leaking oil during their investigation.

Once the causes of the issue have been identified, the final step is to implement solutions to reduce the risk of future problem.  This is where a lot of investigations get tricky.  It is often easier to identify the problem than to actually solve it. It can be difficult to determine what level of risk is acceptable and how many resources should be allotted to an issue.  The cracks in the hull of the Manolis L have been patched using weighted neoprene sealants and a cofferdam has been installed to catch any oil that leaks out.  The vessel is being monitored by the Canadian Coast Guard via regular site visits and aerial surveillance flights. But the oil remains in the vessel so there is the potential that it could be released into the environment.

Many local residents are fighting for the oil to be removed from the sunken ship, rather than just contained, to further reduce the risk of oil being released into the environment. But removing oil from a sunken ship is very expensive.  In 2013, it cost the Canadian Coast Guard about $50 million to remove oil from a sunken ship off the coast of British Columbia. So far, officials feel that the measures in place are adequate and that the risk doesn’t justify the cost of removing the oil from the vessel. If they are right, the oil will stay safely contained at a fraction of the cost of removing it, but if they are wrong there could be lasting damage to local communities and wildlife.

In situations like this, there are no easy answers.  Anybody who works to reduce risk faces similar tradeoffs and generally the best you can do is to understand a problem as thoroughly as possible to make an informed decision about the best use of resources.