By Kim Smiley
On Friday, November 23, 2012, a massive gas explosion rocked downtown Springfield, Massachusetts. No one was killed because the area had been evacuated while a suspected gas leak was investigated, but 20 people were injured and many buildings were damaged.
This incident can be analyzed by building a Cause Map, an intuitive, visual way to perform a root cause analysis. The first step when creating a Cause Map is to document the basic information in an Outline and determine how the goals were impacted. In this example, the safety goal was impacted because there were injuries as well as the possibility for fatalities. The material goal was impacted because 42 buildings were damaged, including three that were immediately condemned. The schedule goal is also impacted because many businesses in the area closed during the necessary inspections and repairs.
Once the impacts to the goals are determined, the Cause Map is built by asking “why” questions. In this incident, buildings were damaged because there was a major gas explosion. This occurred because there was oxygen, a spark and a natural gas leak. Investigators have not been able to determine the source of the spark and may not be able to answer that question due to the extent of the damage. The gas company has released information on what caused the gas leak.
Someone had called in to report a gas smell in the area and the gas company had sent workers out to investigate and evacuated the area at some point during the process. The explosion occurred because a high pressure gas pipeline was inadvertently punctured by a worker who was investigating the reported gas smell. He was using a long metal tool to probe the ground looking for gas underground when the tool accidently hit the pipeline, creating a gas leak. This occurred because the worker wasn’t aware of the location of the pipeline. He was using markings on the sidewalk that indicated the location of the pipeline, but the markings didn’t show the correct location. He moved to what he thought was a safe distant from the location of the pipeline, inserted the tool into the ground and struck the incorrectly marked pipeline. The gas company has stated that the worker was following standard procedure.
It’s also worth noting that none of the injuries were life threatening. If the area hadn’t been evacuated at the time of the explosion there would likely have been many fatalities. At least one local business that would have been opened at the time of the explosion was completely leveled.
To view a high level Cause Map of this incident, click “Download PDF” above.