Monthly Archives: December 2012

Root Cause Analysis - Incident Investigation

Shattering Glass Cookware

By Kim Smiley

Did you know that glass cookware comes with directions?  Many consumers aren’t aware of that fact or know that there is a risk of their trusty cookware shattering if the directions aren’t followed.

This issue can be analyzed by building a Cause Map, a visual root cause analysis.  To begin the Cause Mapping process, an Outline is filled in with the basic background information.  The impact to the goals is also listed in the Outline.  In this example, the safety goal is impacted because there is a possibility of injury if glass cookware shatters.  The schedule goal is also impacted because of the possibility of messes and ruined meals.  This issue has also generated some negative publicity so it is also an impact to the consumer service goal.  The next step is to ask “why” questions to determine what things contributed to the issue.  These causes are then added to the Cause Map to visually show the cause-and-effect relationships between them.

In this example, the glass cookware explodes because it is subjected to temperature swings and it isn’t able to withstand the change in temperature.   Modern glass cookware isn’t as resilient to temperature changes because it is made of a different material.  Starting in the 1980s, glass cookware started to be manufactured using soda lime silicate glass.  Originally, glass cookware was made with borosilicate glass, which is significantly more resilient to temperature changes.  The change occurred because soda lime silicate is cheaper, more resilient to impacts and better for the environment.

Many consumers aren’t aware that modern glass cookware is different from what they may have grown up using.  As a result, consumers may not be following the new directions and this may cause the cookware to explode.  Many consumers may not even be aware that glass cookware comes with directions.  The directions can be found on the manufactures’ websites if the original packaging was tossed.

A recent article in the American Ceramic Society Bulletin that looked into the issue found that modern glassware is far less resilient to temperature changes and concluded that the margin of safety is borderline.  Consumer Reports also looked into the issue in 2009 with a dramatic video showing shattering cookware.  Consumer Reports warned people to carefully read safety warnings.  Manufacturers of the products stand by their products and are fighting to have the American Ceramic article retracted.  Visit the Pyrex and Anchor Hocking’s website for more information.

If you would like to report an incident of shattering cookware, please contact the Consumer Product Safety Commission at 800-638-2772 or info@cpsc.gov.

Root Cause Analysis - Incident Investigation

The Dangers of Distracted Walking

By Kim Smiley

By now, most of us have heard about the dangers of distracted driving and many states have laws restricting the use of cellphones while driving.  But did you know that walking while distracted is also a potentially dangerous habit?  Researchers observed people crossing the street at busy intersections and determined that people using cellphones or listening to music were significantly more likely to do something risky.  More study needs to be done to understand exactly how distracted walking might be contributing to actual accidents, but it is known that the number of pedestrians killed and injured last year increased from 2010.

This issue can be analyzed by building a Cause Map, a visual, intuitive method for performing a root cause analysis.  The first step in building a Cause Map is to complete an Outline that lists all the basic information about an issue.  The bottom portion of the Outline should also be filled in with how the issue impacts the overall goals.  In this example, there was an increase in pedestrians’ deaths which is obviously an impact to the safety goal and there would be more traffic disruptions because there are more pedestrian accidents occurring.  The next step is to ask “why” questions to determine the causes that contributed to an issue.  The causes are then visually laid out on the Cause Map to show cause-and-effect relationships between them.  Click on “Download PDF” above to view an Outline and high level Cause Map of this issue.

Starting with the safety goal, the Cause Map shows that the number of pedestrians killed has occurred because of the increase in pedestrian accidents.   More research is needed to determine exactly why the number of pedestrian accidents is increasing, but there are a couple of likely causes that should be evaluated.  Based on the evidence that distracted pedestrians act in a risky way, such as not looking  both ways and crossing slower, it’s likely that is a contributing cause.  Use of cellphones, both to talk and text, and the use of headphones is becoming increasinglycommon in our culture so it would be worth researching if this has in fact contributed to increase in pedestrian accidents.  Since it still requires research to validate this cause, it is listed on the Cause Map, but a “?” is included to show that it haven’t been confirmed.  As more information is available, the Cause Map can be updated to reflect any new information.

Some solutions to this problem have already been proposed such as laws restricting cellphone use while walking similar to the distracted driving laws and public awareness campaigns since this issue hasn’t been highly publicized.  The report by the researchers who observed pedestrian habits can be viewed here.

Root Cause Analysis - Incident Investigation

40 Percent of Food in America is Wasted

By Kim Smiley

A report by the Natural Resources Defense Council found that a shocking 40 percent of food in America is wasted.  This means that a huge amount of resources are being used to produce food that is never eaten.  Even worse, this food is left to rot in landfills, which produces the greenhouse gas methane.   Landfills are responsible for 34 percent of all methane emissions in thee United States.

This issue can be analyzed by building a Cause Map, a visual format for performing a root cause analysis.  The first step in Cause Mapping is to fill in an Outline with all the basic information and determine the goals that are impacted.  In this example, the environmental goal is impacted because of the increase of greenhouse gases in the atmosphere and the production goal is impacted because $165 billion of food wasted in United States this year.  Once the impacts are determined, the Cause Map is built by asking “why” questions and adding the answers until the cause-and-effect relationships between all the factors that contributed to an issue are clear.

Starting with the environmental goal, the next step is to ask “why” greenhouse gases are being produced.  Methane, a greenhouse gas, is being produced by the tons of food rotting in landfills.  Tons of food is in landfills because 40 percent of the food in the United States is wasted and that is generally where it ends up.  There is such a large amount of  food waste because there is waste at every step of the food chain and there is little motivation to stop wasting food.  There isn’t sufficient motivation to curb the waste because food is relatively cheap and plentiful in this country.  People are also unaware of the scope of the problem and don’t realize that rotting food is a significant environmental issue.

There are a number of reasons that food is wasted at the different steps in the food chain.  About seven percent of food in the United States never even leaves the field.  A number of things cause this, such as more crops being planted than needed to hedge against bad weather or disease, fluctuating food prices making the harvest prohibitively expensive, and produce that doesn’t meet the size and color standards.   There is a lot of waste post-harvest because edible food is culled that doesn’t always meet the high aesthetic standards of this country.  Grocery stores’ practices also result in a lot of wasted food because they overstock products so they don’t look empty and toss a lot of food that is near or at its sell by dates.  Food services and restaurants also contribute to food waste.  It’s estimated that seventeen percent of the food is left on plates by diners, partly because of the ever increasing portion sizes.  Finally, it’s worth note how much food is wasted in the average American household.  It’s estimated that families throw out between 14 and 25 percent of all food and beverages they purchase.

There will always be some waste associated with food production, but there are simple ways to improve.  Better meal planning, eating more leftovers, lower aesthetic standards for produce, and better understanding of sell by dates by consumers would all help.

Root Cause Analysis - Incident Investigation

112 Killed in Garment Factory Fire in Bangladesh

By Kim Smiley

At least 112 were killed in a fire at a garment factory in Bangladesh on November 25, 2012. Officials are still investigating what caused the fire, but many disturbing facts about the disaster have already come to light.

This fire can be analyzed by building a Cause Map, a visual root cause analysis.  When constructing a Cause Map, the first step is to fill in an Outline that lays out the basic facts of the incident.  The impacts to the goal are also listed in the Outline and are used as the first box in the Cause Map.  The Cause Map visually lays out the different things that contributed to an issue and shows the cause-and-effect relationship between the different causes.  In this example, the safety goal was the focus because of the number of lives lost.

So many lives were lost because people were working in the garment factory, there was a fire in the factory, workers were unable to quickly leave the factory and the fire burned for a long time.  People were working in a garment factory because this type of factory work is very common in Bangladesh.  Bangladesh is the world’s second largest producer of garments and work in the industry is one of the main sources of stable income available.  About a third of the population of Bangladesh lives in extreme poverty.  Many of the garment workers are also women, who have limited options for employment.   Investigators have not determined what started the fire, but some government officials have speculated that it may have been arson or sabotage.  Workers were unable to get out of the factory quickly because there was only one exit and the stairways were partially blocked by piles of garments.  There were no emergency exits or fire escapes.  The fire burned all night because it was difficult for fire fighters to reach the factory because it wasn’t easily accessible by vehicles.

As sad as this story is, it was nearly a much worst tale.  It was after normal working hours and many workers had already left the factory.  About 1,500 workers were employed at the factory, but only 600 workers remained working overtime.

The factory produced garments for Western companies such as Disney, Sears and Wal-Mart.  It is not clear if companies were aware that their products were being produced in dangerous conditions and there is some confusion with the use of subcontractors, but this fire raises difficult questions. What responsibility do companies have to the workers producing their clothing?  Thousands of garment workers have protested demanding justice for those killed.  This issue is farther complicated by the fact that some workers are grateful for the work and willing to work in substandard conditions because it’s better than the alternatives.

This issue is also reminiscent of a fire that killed 146 garment workers in 1911 in New York City.   The public outrage following the 146 deaths helped lead to many improvements in worker safety in the United States.  Click here to view a previous blog on this incident.