Monthly Archives: September 2010

Root Cause Analysis - Incident Investigation

Dig Deeper to get to the Causes of the Oil Spill

By ThinkReliability Staff

On Sunday (September 26th, 2010) the lead investigator for the Deepwater Horizon oil spill was questioned by a National Academy of Engineering committee.  The committee brought up concerns that the investigation that had been performed was not adequate to address all the causes of the spill.  Said the lead oil spill investigator: “It is clear that you could go further into the analysis . . . this does not represent a complete penetration into potentially deeper issues.”

Specifically, the committee was concerned that the study focused on decisions made on the rig (generally by personnel who worked for other companies) but did not adequately consider input from these companies.  The study also avoided organizational issues that may have contributed to the spill.

In circumstances such as this one – where an extremely complicated event requires an organization to spend most of its resources fixing the immediate problem, an interim report – which may not delve deeply into underlying organizational issues or obtain a full spectrum of interviews – may be appropriate.  However, it’s just an interim report and should not be treated as the final analysis of the causes relating to an issue.  The organizations involved need to ensure that after the immediate actions – stopping the spill, completing the cleanup, and compensating victims – are complete, an in-depth report commensurate with the impact of the issue is performed.

In instances such as these, causes relating to an incident need to be unearthed ruthlessly and distributed freely.  This is generally why a governmental organization will perform these in-depth reviews.  The personnel involved in the investigation must not be limited to only one organization, but rather all organizations that are involved in the incident.  Once action items that will improve safety and processes have been determined, they must be freely distributed to all other organizations participating in similar endeavors.  The alternative – to wait until similar disasters happen at other sites – is unacceptable.

Root Cause Analysis - Incident Investigation

Largest Egg Recall In US History

By Kim Smiley

Two Iowa farms have recently been at the center of the largest egg recall in US history.  Over half a billion eggs were recalled in August after more than 1,500 people were sickened by eggs tainted with salmonella.

How did this happen?  Where did the contamination come from?  How did tainted eggs make it onto supermarket shelves?

The investigation is still ongoing, but we can begin a root cause analysis of this problem by building a Cause Map.  A Cause Map provides a simple visual explanation of all the causes that were required to produce the incident.  A good place to start building a Cause Map is to identify the impacts to the organizational goals.  Causes are then added to the map by asking “why” questions.  (Click on the “Download PDF” button to view a Cause Map of this issue.)

In this example, we’ll consider the safety goal first.  The safety goal was impacted because nearly 1,500 people got sick because they consumed eggs that were contaminated with salmonella.  Why did they eat contaminated eggs?  Contaminated eggs were eaten because they were sold.  Why?  Because the eggs were contaminated at some point and there was inadequate regulation to prevent them from being sold.

Investigators are still determining the exact source of the contamination, but there is significant information available that can be added to the Cause Map.  The eggs were contaminated with salmonella because the hens laying the eggs were contaminated. (This strain of bacteria can be found inside a chicken’s ovaries and is passed on to eggs.)  The exact source that contaminated the hens is still being determined, but testing by the FDA has determined that the hens were likely contaminated after arriving at the farms.  FDA investigators have found a number of sanitation violations, including rodents which are a known carrier of salmonella.  Salmonella is not passed from hen to hen, but is typically passed from rodent droppings to chickens.

As more information comes available we can add to the Cause Map.  Hopefully, the investigation will result in solutions that can be applied and prevent this situation from occurring again.

Root Cause Analysis - Incident Investigation

Golfer Burns Up the Course…Really

By Kim Smiley

On Saturday, August 28 2010, a golfer at the Shady Canyon Golf Course in Irvine, California had a bad day on the course, a really bad day.

He literally burned the course up.

He swung his golf club and accidentally hit a rock.  This put into motion a classic example of cause and effect.  The metal on rock contact produced a spark, which landed on the dry brush in the area.  This tiny spark eventually grew into a 25 acre wild fire that took 150 firefighters, 38 trucks, 53 helicopter drops and 22,000 gallons of water to finally put out.  No one was injured and no homes were destroyed, but it was still an impressively bad day of golfing.

At first glance, this might seem like a freak accident that isn’t worth expending resources to investigate.

But what if this wasn’t the first time something like this happened?

The manager of the course stated that a similar incident happened a few years ago, but the golfer had been able to put the fire out before it could spread.

It seems like it might be worth at least considering possible solutions.

A root cause analysis can be performed by building a Cause Map using the information from this example. A Cause Map provides a simple visual explanation of all the causes that were required to produce the incident.  Cause Maps can be very detailed and include hundreds of causes or can be very high level.  It depends on the type of problem being investigated.  In this case, a fairly simple Cause Map should be adequate to brain storm some possible solutions.  Click on the “Download PDF” button above to view a high level Cause Map.

In this example, there are a number of possible solutions.  The course could be watered more often so that the brush isn’t quite so dry, fire extinguishers could be put on golf carts during the dry season to extinguish any fires that occur before they have a chance to grow, more rocks could be removed from the course and surrounding areas, etc.  There are many solutions that could be implemented.  Once the issue is clearly understood and the causes determined, the most effective, cost effective solutions can be implemented.

Root Cause Analysis - Incident Investigation

A Serendipitous Solution

By Kim Smiley

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.