Monthly Archives: October 2011

Root Cause Analysis - Incident Investigation

Severe Flooding in Thailand

By ThinkReliability Staff

Thailand is experiencing an unusually heavy monsoon season, but it’s management of the rains that are being blamed for the most severe flooding to occur in the area in decades.  Heavy rains resulting from the monsoon season and high tides are creating serious difficulties for officials in the area, who are having to make hard choices with where to divert water and are essentially “sacrificing” certain towns because there’s nowhere else for the water to go.  One of these decisions ended in a gunfight.  Tensions are high, and people are busying themselves attempting to protect their homes and towns with hundreds of thousands of sandbags.

We can examine the issues contributing to the risk to people and property in a Cause Map, or visual root cause analysis.  First, we define the problem within a problem outline.  In the bottom portion of the outline, we capture the impacts to the country’s goals.  More than 200 people have been reported killed as a result of the floods, which are themselves an impact to the environmental goal.  If citizens can be considered customers, the decision to “sacrifice” some towns to save others can be considered an impact to the customer service goal.  The  property goal is impacted by the destruction of towns and the labor goal is impacted by the flood preparations and rescue missions required to protect the population.

Beginning with these goals and asking “Why” questions, we can diagram the cause-and-effect relationships that contribute to the impacts discussed above.  The decision to “sacrifice” some towns to save others is caused by flooding due to heavy monsoon rains and high tides, and the fact that water had to be directed towards some towns, as there is nowhere else for the water to go.  Towns have been built in catchments and areas designed to be reservoirs. Natural waterways have been dammed and diverted.  Dams are full because insufficient water was discharged earlier in the season due to a miscalculation of water levels. Canals have been filled in or are blocked with garbage.  Insufficient control of development in the area has led to insufficient control of water flow, and lack of areas for water to gather – without endangering towns.

Thailand officials are assisting with sandbags and building new flood barriers and drainage canals.  They’re admitting that this issue needs to be repaired.  According to the director of the National Disaster Warning Center, “If we don’t have integrated water management, we will face this problem again next year.”  Hopefully this is the first step in making changes that ensure loss of life and property is minimized during the annual rainy season.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more

 

Root Cause Analysis - Incident Investigation

Driver Death at Indy 300

By Kim Smiley

The racing world was filled with sadness with the death of Dan Wheldon during the Indy 300 race in Las Vegas on October 16, 2011.  However, many race-car drivers were not shocked at the occurrence of a 15-car pileup that resulted in Wheldon’s death.  Specifically, these drivers note that the track – which was designed for NASCAR vehicles which travel at much slower speeds – was designed with high banks that allowed cars to accelerate heavily, reaching speeds of up to 225 miles per hour.  This also contributed to the cars remaining very close together, leaving little time or space for drivers to maneuver.  Although the track was smaller in diameter than other tracks (1.5 mile oval compared to the Indy 500’s 2.5 mile oval), it allowed 4 cars to race side by side, as was happening at the time of the crash.

Drivers say that the design of the track, the speed of the cars, and the unusually high number of competitors (34, when a full field is generally 26-28 cars) contributed to the crash.  Also, the open wheel design of Indy cars means that the driver has less control when contacting other cars.  In fact, many drivers said they expected at least one spectacular crash to result, given the circumstances.  Although racecars do have special features that protect drivers in a crash, the cars used in the Indy races have open cockpits, providing less protection.  It also appears that the protective roll hoop was missing on Wheldon’s car, though more information on this has not been released.

Other drivers were also injured in the 15-car pileup, though their injuries were not critical and all others have been released from the hospital.  Wheldon was said to have suffered “unsurvivable head injuries”.   After Wheldon’s death, the race – which had a $5 million prize in hopes to boost ratings – was stopped.   This is the first fatality to occur in Indy racing since 2006.  It is hoped that new safety measures – which Wheldon had been involved with – will continue to make Indy racing safer.  However, there are some drivers that believe that regardless of the safety features in the cars, Indy racing should be done on street courses, not ovals.

To view the Outline and Cause Map, please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Toxic Fumes on Aircraft

By ThinkReliability Staff

A settlement against an aircraft manufacturer, with regards to a claim that faulty design allowed toxic fumes to enter the cabin, occurred in early October 2011.  It is the first of its kind to occur in the U.S., but may not be the last.  A documentary entitled “Angel Without Wings” is attempting to bring more attention to the issue, which air safety advocates claim has affected the health and job-readiness of some airline crewmembers.

Although the aircraft manufacturing and operating industries maintain that the air in cabins is safe, breaches are rare, and that the small amount of toxicity that may get into the cabin is not enough to affect human health, the issue is expected to gain more attention, as some industry officials maintain that approximately one flight a day involves leakage of toxic fumes into the passenger cabin of an aircraft.  Although there is debate about the amount of fumes required to cause various health effects, allowing toxic fumes of any amount into a passenger cabin is an impact to both the safety and environment goal.  Additionally, the lawsuit – and the potential of more to come – against the manufacturer is an impact to the customer service goal.  Although the suits have been brought by crew members, there is also a concern for the safety of passengers with respect to exposure to the contaminated air.

The toxic smoke and fumes enter the plane’s air conditioning system when engine air gets into the bleed-air system, which directs air bled from engine compressors into the cabin.  Because there is currently no effective way for crew members to determine that the air is contaminated – no detectors and insufficient training for these crew members to recognize the source and possible outcome of the fumes – the air continues to be fed to the cabin. The creators of the documentary, and other air safety advocates, are requesting that better filters be installed to prevent the toxic fumes to enter the cabin, less toxic oil be used so that the fumes from any leaking oil are less damaging to human health, that detectors be installed in air ducts to notify crew of potential toxicity in the air supply, and better education and training to help crew members identify the potential for exposure to toxic fumes.  However, the manufacturer’s newest design makes all this unnecessary by using an aircraft design that provides air from electric compressors.  Given the length of time that aircraft remain in the air, it will be decades before the system may be phased out.  In the meantime, advocates hope that other corrective actions will be implemented to decrease the potential of exposure to passengers and crew.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause Analysis - Incident Investigation

1982 Tylenol Tampering

By ThinkReliability Staff

In 1982, 31 million bottles of Tylenol were recalled after seven deaths from cyanide poisoning.  After an investigation, higher than lethal doses of cyanide were found to have been inserted into bottles of Extra-Strength Tylenol capsules in retail stores in the Chicago area. Tylenol’s manufacturer, Johnson & Johnson, immediately took action and recalled all Tylenol products.

Although the reason for the poisoning is unclear – the suspect has still not been caught, though interest in the case has recently been revived – what was clear is that the ability to tamper with a product in such a malicious way without the tampering being evident contributed to the deaths.  As a result of this issue, capsules (which are much easier to insert foreign objects into than solid pills) decreased in use, and tamper-evident packaging became used for many products.

Although the manufacturing and packaging process were not implicated in the poisonings (the adulterated packages were from different plants, but all came from stores within the Chicago area), there was concern that Tylenol would never again be popularly accepted.  However, Johnson and Johnson’s quick and effective action in the immediate recall of all products and public relations campaigns to urge people not to use products until the issue had been resolved has been considered a playbook on how to conduct an effective recall and is believed to have directly contributed to the resurgence in the popularity of Tylenol shortly after the issue.  (See “How Effective Public Relations Saved Johnson and Johnson“.)

Even though this case hasn’t been resolved, and the killer still remains unknown, it is possible to examine the issue with a Cause Map.  Because this case has stretched over many years, a timeline can help to sort through information.  The outline contains the many impacts to the goals related to the issue, and the Cause Map sorts through causes – both “good” and “bad” – related to the issue.  Solutions implemented to decrease the ability to tamper with consumer products are also noted.