By ThinkReliability Staff

At approximately 5:00 p.m. on October 17, 2003, a fire began in a storage closet on the 12th floor of a Cook County Administration Building in Chicago. Since there were no Fire Safety Director personnel at the building, the building engineer decided to evacuate.  The Emergency Voice/Alarm Communications (EVAC) system was activated, informing personnel that they should evacuate the building using any set of stairs.  The Chicago Fire Department (CFD) was called and began fighting the fire from the southeast stairway on the 12th floor.

Personnel evacuating from above the 12th floor in the southeast stairway were stopped at the 12th floor by firefighters and told to go back.  When they did, they found all the doors locked up to the 27th floor.  However, before all the evacuees on the stairway could make it up to the 27th floor, the firefighters opened the stairway door to fight the fire.  This, combined with a smoke tower system that may not have been functioning correctly, led to the stairway filling with smoke and toxic gases, which overcame several people on the stairs.  Six of these people died.  The last body was found in the stairway approximately 90 minutes after the fire began.

A report commissioned by the Governor of Illinois found multiple issues that led to the deaths.  There was no s sprinkler system, which allowed the fire to spread.  The stairway doors were locked, and the evacuees and CFD personnel were generally unaware that they’d be locked, since there was no evacuation procedure or mandatory fire drills in the building.  The building had a Fire Safety Director, who was not certified and was 40 minutes away from the building when the fire occurred, and no deputies.  The firefighters appeared to place a priority on fighting the fire over searching for trapped people, even after several 9-1-1 calls indicated there were personnel trapped on the stairs.  Miscommunication and a lack of leadership within the CFD meant that 90 minutes elapsed before victims were found in the stairway.  Had they been found sooner, more would have survived.  Additionally, the fire department did not follow certain procedures, such as breaking windows above and below the firefighting site to allow smoke to escape and searching the area before opening a door that was trapping smoke.

A thorough root cause analysis built as a Cause Map can capture all of these causes in a simple, intuitive format   that fits on one page.  To view the complete investigation in visual form, click on “Download PDF” above.

A Cause Map also captures proposed solutions.  A solution is tied to a particular cause on the map.  Solutions are placed directly above the causes they control.  Some of these solutions have already been implemented, and many are valid for any high rise building to consider implementing.

Learn more about the Cook County Administration Building fire.

By Kim Smiley

A recent report by a White House panel of independent space experts says NASA’s current goal to return to the moon isn’t feasible with the current budget. The panel estimates that NASA would need about $3 billion extra a year beyond the current budget to continue with human space flight.

The budget shortfall is obviously a problem that may prevent NASA from meeting their overall organizational goals.  A root cause analysis built as a Cause Map can be created to understand how this issue developed.

In this case, the production goal is impacted because NASA is likely to be unable to meet the stated goal of a moon mission by 2010.  This is caused by the high cost of a moon mission, other budget considerations (such as the cost of possibly extending the moon mission and the International Space Station) and the limited NASA budget.  The causes of each of these can then be explored.

NASA has been working toward a return to the moon because five years ago then-President George W. Bush stated that NASA should work to return astronauts to the moon, with a proposed date of 2020.  NASA has already spent $7.7 billion working toward this goal, including the design and the construction of new rockets.

Part of the plan to pay for this venture was to retire the space shuttle in 2010 and deorbit the International Space Station in 2015, but the panel also recommended revaluating these deadlines, which would add additional budget pressure.

The panel found that extending the life of the space station beyond 2015 would allow a better return on the billions of dollars invested into it.  The panel also felt the space shuttle should be evaluated for possible life extension as well in order to continue to service the space station, since there is no viable alternative that will be developed in the necessary time frame.

NASA budget continues to be limited as national budget constraints increase.  In order to raise funds, the panel also recommended including other countries and private-for-profit firms in addition to increasing NASA budget.

This problem has no easy, clear solution.  Only time will tell how President Obama will choose to respond to these findings and if human space flight will continue to be a goal for NASA.

By ThinkReliability Staff

San Francisco’s 73-year old Bay Bridge partially collapsed during the Loma Prieta earthquake of  1989.  As a result, a seismic upgrade project was planned.  The bridge closed Thursday night, September 3rd, 2009, as part of the upgrade project.  Authorities conducted a thorough inspection of the bridge while it was closed.  During this inspection, an eyebar was found to be cracked about halfway through.

Unfortunately for San Francisco,  “The crack is significant enough to have closed the bridge on its own” says Caltrans spokesman Bart Ney.  Thus the area quickly made plans for repairing the bridge, which would necessitate closing it for longer than just Labor Day weekend, as planned.   However, commuters received a pleasant surprise when the bridge opened  at about 6:30 on Tuesday morning, less than two hours after originally planned (before the cracked eyebar was discovered).Construction crews worked around the clock to get the bridge repaired and inspected before morning rush hour.

Was it worth the rush?  Ask the 260,000 commuters who normally cross the bridge every day.   However, local transit officials did not rely on the bridge opening on time.  Instead, they made other arrangements, including adding high-speed catamarans to the ferry line-up.

This is an excellent demonstration of the use of “Plan B”, or implementing multiple solutions for issues with great impacts to the goals.  In this case, the repairs were necessitated by the possible loss of the bridge – certainly an impact to the goals of a transit authority.  The accelerated repair schedule and additional transit options were necessitated by the potential loss of the bridge as a transportation route during high traffic-volume times, resulting in an impact to the customer service goal.

By Kim Smiley

In recent years, the cost of attending a college in the US has risen about three times faster than inflation and the average student loan amounts have increased accordingly.  Combine this with the highest unemployment rates of college graduates since 1979 (4.8% in May, up from 2.1% at the start of the recession) and lower starting salaries during recessions, and there are many recent graduations struggling to make their loan payments.

As with any problem, it is possible to perform a root cause analysis of the issue. To begin let’s assume the production goal of an individual considering college is to earn a comfortable living and the potential impact to this goal will be difficultly making loan payments.

The causes of this potential problem repaying loans could be unemployment after graduation, lower starting salaries for new hires during a recession and large loan payments.  The causes of each of these factors can then be explored.  Click on the Download PDF graphic above to view an intermediate level Cause Map with more causes added.

A recent USA Today article entitled “In a Recession, Is College Worth It? Fear of Debt Changes Plans” discussed how many students are rethinking their college plans.  Enrollment at community college is soaring and many students are choosing a less expensive option and skipping the big name private institutions.

This makes sense when considering the potential difficulty repaying college loans because the only cause that the student has direct control over is the size of the loan payments.

The bottom line is that each individual needs to think through their particular situation, consider how much the college costs and how much the starting salary for their particular degree is projected to be.  There are very real dangers in amassing large student loans without calculating the monthly payments and ensuring that they are within a realistic budget.

The reality is that some universities cost more and there is no guarantee that attending a more expensive college will result in a higher salary.  It may well be a smart decision to choose a less expensive option when selecting a college.

If you’re interested in reading an analysis of the 2009 Financial Mess, please click here.