Monthly Archives: October 2012

Root Cause Analysis - Incident Investigation

Rogue Ocean Fertilization Experiment Done

By Kim Smiley

An entrepreneur created a massive bloom of plankton after he dumped a hundred tons of iron dust into the Pacific Ocean off western Canada last June.  This action has sparked outrage because an individual manipulated the environment without government approval or scientific oversight.

A Cause Map, a visual format for performing a root cause analysis, can be built to analyze this issue.  The first step in building a Cause Map is to determine how the issue impacts the overall goals.  The next step is to ask “why” questions and the answers are then organized into cause-and-effect relationships so that all factors that contributed to a problem are laid out in an intuitive format.  In this example, impacts to several goals are worth considering.

The first issue is that nobody knows exactly how the environment will respond to this much iron being put into the ocean.  The environmental impacts may well turn out to be minimal, but this is by far the largest experiment of this type done to date so nobody really knows how big the impact will be.  The experiment is also particularly worrisome because there wasn’t adequate scientific oversight or approvals for it.  The man conducting the experiment was an entrepreneur hoping to make money.  A local tribe hired the entrepreneur to fertilize the ocean with iron in a bid to increase the local salmon population by increasing their food supply.  Adding iron to the ocean can create a rapid increase in the phytoplankton population, which are the base of the aquatic food chain, because iron is often the limiting nutrient for phytoplankton growth.  Iron is necessary for photosynthesis and thus phytoplankton growth.  But iron is also highly insoluble in sea water so large areas of the ocean have limited iron supplies.

The entrepreneur also hoped to find a way to cash in on carbon offset credits because phytoplankton blooms may be a way to sequester carbon and improve greenhouse gas numbers in the environment.  This may work because phytoplankton absorb carbon dioxide during their life and when they die they sink into the ocean, taking the carbon dioxide with them and removing it from the atmosphere.

The second issue is that there are known risks associated with large blooms of phytoplankton.  They can negatively affect the other aquatic life in the region because large blooms can deplete the ocean of oxygen.  This occurs because the populations of other microorganisms will increase since the increase in phytoplankton provides a larger food supply.  Some of these other microorganisms absorb oxygen so more of them means less oxygen for other aquatic life. Phytoplankton live near the surface, but they sink as they die so a bloom will impact the food supply and oxygen levels throughout the entire depth of the ocean.

A final goal worth considering is the impact this has on public opinion.  Iron fertilization is a contentious issue to begin with because many people are opposed to purposefully manipulating the environment.  When somebody dumps tons of iron into the ocean without solid scientific involvement it understandablely outrages the public. The negative press will make it harder for any legitimate scientific research being done in this field.

This issue has been covered by The New York Times , The New Yorker  and NBC news. Click on any of these links to learn more about this issue.  Click on “Download PDF” above to view a high level Cause Map.

 

Root Cause Analysis - Incident Investigation

Toyota Recalls Millions of Vehicles Because of Fire Risk

By Kim Smiley

On October 11, 2012, Toyota announced a recall of 7.4 million vehicles worldwide due to a potential fire hazard.  This newest recall comes on the heels of the heavily publicized unintended acceleration issue and puts Toyota once again in an unwanted spotlight.

A Cause Map, a visual format for performing a root cause analysis, can be built to help analyze this issue.  The first step in building a Cause Map is to create an Outline that lays out how the issue impacts the overall goals of an organization.  In this example, the safety goal is impacted because of the potential for injuries and car accidents.  The production goal is impacted because of the effort needed to recall millions of vehicles.  The customer service goal is also impacted because of the negative publicity that a recall of this size will generate.  After the impact to the goals is determined, “why” questions are asked to determine what causes contributed to the issue and to create the Cause Map.

Starting with the production goal, we would ask “why” millions of vehicles were being recalled.  This is happening because there is a component that may need to be repaired, the component is in many vehicles and there is a potential for injuries if the component isn’t repaired.  A component needs to be repaired because the power-window switches pose a fire risk.  Some of the power-window switches feel sticky when operated and if some commonly available lubricants are applied it will create a fire hazard because the switch can melt.  There are millions of these power-window switches to repair because they were used across multiple models for several years because using standard parts is usually cheaper.  There is a potential for injuries because a fire starting in the power-window switch while the car is driving would be pretty distracting.

This recall will generate negative publicity because it is a huge recall, the a largest vehicle recall since Ford Motor Co recalled 7.9 million vehicles in 1996, and the timing is a bit unfortunate since it comes shortly after the unintended acceleration issues that resulted in large recalls.  In fact, some of the vehicles being recalled this round are the same vehicles that have had previous recalls, a fact that probably isn’t reassuring to owners.

The good news is that the fix for this problem is relatively simple beyond the innate hassle of taking a vehicle to the dealer.  The recall consists of a technician inspecting, disassembling and applying approved fluorine grease to the power-window switch, improving the sticky operation and decreasing the likelihood that some handy soul might apply an unapproved lubricant and inadvertently melt the part.

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

Root Cause Analysis - Incident Investigation

Supply of Disposable Diapers Threatened by Explosion at Chemical Plant

By Kim Smiley

On September 29, 2012, an explosion at a chemical plant in Japan killed a fire fighter, injured 35 others and did significantly damage.  Chemicals produced at the plant are used in disposable diapers.  The damaged plant will be inoperable for the foreseeable future, which will likely impact the global supply of disposable diapers, a thought that strikes fear in the hearts of many parents of small children.

This incident can be analyzed by building a Cause Map, an intuitive, visual format for performing a root cause analysis.  The first step in building a Cause Map is to identify which goals were affected.  In this case, the safety goal is obviously impacted since there was a fatality and injuries.  The production goal is also a major consideration since the supply of disposable diapers is threatened because the plant will be unable to produce chemicals for a significant amount of time.  The next step is to ask “why” questions to add additional boxes to the Cause Map.

Starting with the safety goal first, we would ask “why” there was a fatality and injuries.  In this example, people were hurt because there was a fire at a chemical plant.  The fire occurred because a tank exploded and it was near other tanks full of flammable chemicals.  The tank exploded because the temperature inside the tank was increasing and it wasn’t cooled in time.  It isn’t clear yet why the temperature was increasing inside the tank, but investigators are working to find the cause.  Once it is known, it can be added to the Cause Map.

At the time of the explosion, efforts were underway to cool off the tank, but they weren’t effective.  Firefighters were working to spray down the tank with cool water to help lower the temperature, but the temperature rose too quickly.  This is also a cause of the fatality.  A fireman was working to connect spray lines near the tank at the time it exploded and he was sprayed with hot chemicals.  Other injuries occurred at the time of explosion and others were sustained during the effort to fight the fire.  It’s possible that one of the reasons that the workers were unable to cool the tank was that the usual method of cooling the tank, injecting nitrogen to decrease the oxygen and control the chemical reactions occurring, might not have been functioning properly.  This is another area that can be clarified on the Cause Map as more information is known.

Looking at the production goal now, a potential shortage of disposable diapers may occur as a result of this accident because the plant produced a significant amount of a chemical used in manufacturing diapers.  This plant produced 20% of world’s supply of one chemical in particular needed for diapers.  Combine this with the fact that the other plants manufacturing this chemical are already operating at maximum capacity and the supply will likely be less than the demand.

The final step in the process is to use the Cause Map to develop solutions to help prevent similar problems from occurring in the future.  It’s premature to discuss specific solutions in this example since the investigation is still ongoing, but the initial Cause Map can easily be expanded and used when all the information is available.

Root Cause Analysis - Incident Investigation

The Dangerous Combination of Hot Cars and Children

By Kim Smiley

Every summer, the news covers heartbreaking stories of children who die after being inadvertently left inside a vehicle.  Since 1998, 527 children have died from heat stroke from being exposed to high temperatures inside a vehicle.  One of the most tragic elements of these stories is that these deaths are preventable.

This issue can be analyzed by building a Cause Map, a visual root cause analysis that intuitively lays out all the causes that contributed to the problem. The first step in building a Cause Map is to determine how the issue affects the overall goals.  In this example, the safety goal is the obvious focus since there have been hundreds of deaths.  The next step is to ask “why” questions and add the answers to the Cause Map.  Why have 527 children died?  They died of heat stroke because they were left inside a car and the interior of the car was hot.  Children also overheat quicker than adults because their thermoregulatory system isn’t as efficient.

The children were left inside the car because they were inadvertently forgotten, a caregiver intentionally left them inside or the children managed to get inside the cars themselves.  There are a number of reasons that a caregiver could forget a small child. The most frightening thing about these incidents is that it can happen to well intentioned, loving parents who simply make a terrible mistake.  These incidents tend to occur most often when there is a change of routine, such as a different parent than normal doing the daycare drop off.  It certainly doesn’t help that many parents and caregivers of young children are tired and potentially sleep deprived. The driver may also not be able to see a small child because many states require backward facing car seats in the back seat.   In the cases where a caregiver intentionally leaves a child and no harm was intended, it’s safe to assume that they didn’t understand the danger.  There are also cases where a child enters a car and becomes trapped inside.  In those examples, the vehicle was most likely unlocked and the caregiver didn’t realize the child was playing in the vehicle.

Vehicles are  especially dangerous because they heat up very quickly to dangerous levels.  A car is an enclosed space with a lot of windows to let in sunlight, making it an ideal situation for temperatures to increase.  Even relatively mild days can result in hot temperatures inside a car.  The temperature inside a car can raise about 40 degrees even when the ambient temperatures are in the 70s, meaning the inside of a car can be over 110 degrees on a fairly cool day.

There are a number of gadgets people have invented to help prevent children from being inadvertently forgotten in a car, but their effectiveness is debated.  The simplest way to prevent this from happening is very low tech; put your purse, shoe or anything that you must have in the backseat.  Another suggestion is to keep a large stuffed animal in the car seat and then move it up to the front passenger seat while the car seat is occupied so that you have a visual reminder of your precious cargo.  The most important thing is to be aware of this deadly problem and have a plan to prevent it if you ever drive around children, especially those strapped into car seats.