Monthly Archives: February 2012

Root Cause Analysis - Incident Investigation

Honduran Prison Fire

By ThinkReliability Staff

How do you know when your solutions haven’t been effective?  When the same problem keeps happening.  Another prison fire claimed 360 lives in Honduras.  This is the third fatal prison fire in nine years, resulting from  chronic overcrowding and understaffing of Honduran jails.

Just more than 3 years since over 100 prisoners were killed in a prison fire  in San Pedro Sula (see previous blog), 360 prisoners (so far) have died as a result of a fire in Comayagua Prison.  (A fire in 2003 claimed the lives of 68 prisoners.)  An open flame has been determined to be the cause of the fire but contributing to the deaths is that the prisoners were unable to get out.

With any incident resulting in deaths of this magnitude, we can analyze the causes of the incident using a visual root cause analysis, or Cause Map.  We begin with the impacts to the goals.  In this case, the prisoner deaths were an impact to the safety goal.  In addition, prison overcrowding can be considered an impact to the production goal, and a delay in rescue can be considered an impact to the customer service.  Any damage resulting to the prison itself as  a result of the fire is an impact to the property goal.  Once we’ve determined the goals that were impacted, we can begin the analysis by asking “why” questions.

An investigation determined that an open flame (such as a cigarette or candle) and not arson, as was suggested prior to the investigation, caused the fire.  However, severe overcrowding (more than 800 prisoners were in a jail with a capacity of 500) and a delay in the rescue of the prisoners contributed to the massive death toll.

Honduras has a chronic overcrowding problem.  Honduras has a high rate of homicides and a high number of gang members.  Gang members receive strict sentences and, in many cases, are jailed prior to conviction.  However, an increased number of  inmates has not led to an increased number of guards.  On the night of the fire, there were 6 guards on duty.  Guards who were in the towers were not allowed to leave their posts to help with the fire-fighting and rescue efforts.  The guard who had the only set of keys fled prior to unlocking the doors.  (The guards are facing disciplinary actions.)  Firefighters were not allowed to enter the jail for 30 minutes after the fire call as the guards believed they were experiencing a riot or breakout.  An inmate who was not in his cell at the time of the fire was able to free many prisoners.

This incident has added more fuel to the international outcry over the state of Honduras prisons.   However, not much appears to have been done to improve conditions since the previous fires in 2003 and 2009, so it’s unclear if anything will change as a result of this fire.   It is certainly apparent that the safety of prisoners cannot be maintained with the current overcrowding and number of guards.  Additionally, procedures in the case of a fire certainly need to be improved to ensure that prisoners can be evacuated safely and securely.

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

Root Cause Analysis - Incident Investigation

Collapse of Gulf of Maine Cod Population Feared

By Kim Smiley

Recent estimates of the Gulf of Maine cod population show that cod is being over fished to the point that the population is at risk of collapse, meaning the numbers become so low the population cannot recover.  Federal regulators are trying to determine the best course of action to protect the fish population which may include severely restricting cod fishing in the Gulf of Maine.

The declining cod population problem can be analyzed by building a Cause Map, an intuitive, visual root cause analysis.  The first step in building a Cause Map is to determine what goals are impacted by the issue.  In this case, the environmental goal is impacted because the cod population may collapse, but the economic impacts of this issue are also a major concern.

Cod has long been a major source of income for New England fishermen, bringing in $15.8 million in 2010.  Restricting cod fishing would also impact the ability to catch other fish because cod is often also bought up in nets when other fish are targeted.  Cod are bottom swimmers along with other popular fish such as flounder and haddock and it’s impossible to catch one type of fish without catching the others.

The cod population is declining because the fish are not reproducing fast enough to keep up with fishing. Fishing of cod occurs for several reasons.    First, cod is caught and sold because it is profitable.  Cod meat is high in protein, low in fat and easily filleted. Additionally, federal regulations allows fisherman to catch a set quota of cod.  One of the potential causes of the declining cod population may be that these quotas are set too high to for the cod population to continue to grow.

The federal limits on cod fishing over the past few years were set based on information from 2008 that showed a significantly higher cod population than the estimates determined by the recent population assessment.  It’s not clear why the numbers of cod varied so dramatically between the current estimates and the ones from 2008, but the dramatic swing in fish population estimates has been a source of many complaints by fishermen.  It may also be worth considering whether any environmental factors have impacted the fish population.  Cod population can be affect by many factors besides fishing, such as varying ocean temperatures or changes in their food supply.

After considering severe cuts of up to 82 percent, federal regulators appear to be willing to reduce the amount of cod allowed to be caught by only 22 percent for the 2012 fishing season.  This is only a one year agreement and fishermen will likely face severe cuts on cod fishing limits again in 2013.   At this time it’s not clear whether there is a way to save the historic fishing industry in the Gulf of Maine and ensure a healthy population of cod in the region.

To view a high level Cause Map of this issue, click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Several Incidents at CA Nuclear Plant Raise Concerns

By Kim Smiley

Within a week, three separate incidents occurred at the San Onofre Nuclear Generating Station, located near heavily populated areas, raising new concerns about the safety of the nuclear power plant.

This issue can be investigated by building a Cause Map, an intuitive, visual root cause analysis.  The first step in building a Cause Map is to determine what goals are impacted by the issue being considered.  In this case, the main goal being considered is safety.  If the Cause Map was being built from the perspective of the power plant company, then the production and schedule impacts would also need to be considered, but in this example we will focus on the safety impacts.

The safety goal is impacted because some people are concerned about the safety of the power plant because it is near heavily populated areas and three separate incidents occurred within days of each other.  The three incidents in question were the release of a small amount of radiation, discovery of unexpected amounts of wear on steam generator tubes, and the potential contamination of a worker.

A small amount of radiation was released because a steam generator tube, which carries radioactive water, was leaking.  Luckily, the leak was small and the plant was quickly shut down after the leak was discovered so no significant amounts of radiation were released.  A second reactor unit is currently shut down for maintenance and inspection of the steam generator tubes found significantly more wear than expected on some of the tubes.  The wear was unexpected because the tubes have only been in service for 22 months and two tubes had 30% wall thinning, 69 tubes had 20% wall thinning and 800 had 10% wall thinning.  The situation is being investigated, but neither the cause of the wear nor the best course of action has not yet been determined.  The final incident was the potential contamination of a worker because he fell into a reactor pool.  According to media reports, the worker was trying to retrieve a flash light and lost his footing.

To view a high level Cause Map of this incident, click “Download PDF” above.  The Cause Map can be expanded as more information comes available so that it can document and illustrate as much detail as needed to evaluate the issues.

As it stands, both the reactor units with the steam generator tubes are shut down.  The unit that experienced the leak is shutdown pending investigation and any necessary repairs.  The second unit that had the unexpected wall thinning in the steam generator tubes is in a planned shutdown of several months while it is refueled and upgraded.  The plants will be brought back online once it’s determined safe to do so.

Root Cause Analysis - Incident Investigation

Prison Fire Kills 103 in 2009

By Staff

On February 9, 2009, a fire and explosion in a seriously overcrowded prison in Honduras resulted in 103 deaths and 25 injuries.  The fire was started from a short circuit from a overheated refrigerator motor, used to store soft drinks for the inmates.  The cell block – which has a capacity of 800 – contained 1960 inmates, their clothing, and their bedding materials.  This provided plenty of fuel for the fire.

We can look at the causes that led to the prisoner deaths in a Cause Map, or visual root cause analysis.  We begin with the impacts to the goals.  The deaths and injuries of prisoners are an impact to the safety goal.  The environmental goal was impacted by the severe prison fire and explosion.  The customer service goal (considering the general population as the “customer” of a government-run prison) was unaffected, as there were no prisoner escapes.  Finally, the property goal was impacted due to damage to the prison.

We can continue the Cause Map by asking “why” questions.  The impacts to the goals were due to a severe prison fire and explosion.  In addition to the fire, the injuries to the prisoners was caused by the prisoners being unable to escape.  Part of the reason the prisoners were unable to escape is because they are in prison, and so precautions against escape are part of the deal.  However, egress from a building that is on fire to a safe location should be part of the procedures of any prison.  In this case, the procedures obviously didn’t work considering the high amount of deaths and injuries (of a total of 186 prisoners in this cell block).  The egress was likely made more   difficult due to severe prison overcrowding.  The prison has a capacity of 800 and contained 1,960 prisoners.  The increase in the prison population is at least partially due to a legislation passed the previous August which mandated a minimum 12-year prison term for gang members.  There are estimated to be more than 100,000 gang members in Honduras.

The heat for the fire was provided by an overheating refrigerator motor.  The fuel was provided by large amounts of clothing and bedding materials – more than usual, due to the prison overcrowding.

Once the causes for the impacted goals have been determined, solutions can be brainstormed.  In this case, prisoner advocates have been long calling for alternatives to jail sentences for gang members.  This would, of course, reduce the prison population.  Another option to reduce prison overcrowding would be to build more prisons.  To reduce the risk of fire, motorized equipment should be kept away from flammable objects, like clothing and bedding.  Last but not least, any facility has to have an effective egress plan in the case of fire or other emergencies.  These procedures are especially important in the case of a prison, where the potential of prisoner escape has to be considered as well as prisoner safety.

To view the root cause analysis investigation, please click “Download PDF” above.  Or click here to read more.