Beijing’s “Airpocalypse”

By Kim Smiley

Beijing’s air pollution was at levels considered hazardous to human health for nearly a week during mid-January 2013.  During this event, colorfully dubbed the “airpocalypse”, pollution levels peaked at 755 as measured by the Air Quality Index (AQI).  This value is considered “Beyond Index” because it is well above the 500 which is considered the maximum AQI value.  Any AQI value over 300 is considered hazardous.

This issue can be analyzed by building a Cause Map, an intuitive format for performing a visual root cause analysis.  The first step in building a Cause Map is to fill in an outline with the basic background information.  The impacts to the organizational goals are also listed in the Outline.  In this example, the safety goal is impacted because people are reporting respiratory issues and there is a possibility of long term health problems because millions were exposed to hazardous air pollution.  The customer service goal has also been impacted because of the negatively publicity that the air pollution issues have generated.  The impacts to the goals are used to build the Cause Map by asking “why” questions.

Why were millions exposed to hazardous air pollution?  This happened because there was air pollution produced in and around Beijing and the pollution was trapped in the city.  A number of sources contributed to the air pollution.  There are many coal burning factories in the area and the amount of coal burnt as a heat source has increased recently because of unusually cold weather.  The number of cars in the city is also increasing at an amazing rate, with thousands more added to the city traffic daily.   There is also a lot of construction in the city needed to meet the demands of such a large population. The pollution was trapped in the city because of the city’s geography and the weather.  Beijing sits on a plain and is flanked by hills.  If the wind doesn’t blow in the right direction to push the  pollution out to sea, it will be trapped by the hills and blanket the city, which is what happened in this case.

The final step in the Cause Mapping process is to develop and implement  solutions to prevent the same thing from recurring.  The Chinese government did take several steps to try to mitigate the  immediate problem with the air pollution by limiting the use of cars and temporarily shutting down some factories.  The pollution finally cleared up as the wind began to blow, but continued efforts will be needed to prevent similar issues in the future.

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

Commuter Ferry Crash in NYC Injures 85

By ThinkReliability Staff

A commuter ferry struck a pier in Lower Manhattan, NY during the morning commute on January 9, 2013, injuring at least 85 people – some critically .  According  to US Coast Guard Captain Gordon Loebl, “We know that they hit the pier at a relatively high rate of speed.”

We can examine this issue in a Cause Map, a form of root cause analysis which provides a visual “map” of cause-and-effect relationships.  We begin by determining the impacts to the goals resulting from this incident.  The safety goal was impacted due to the large number of people who were injured.  (No fatalities have been reported as a result of the crash.)   The customer service goal was impacted because the ferry slammed into a pier (nobody expects that on their morning commute!).  The ferry was damaged, impacting the property goal.  Presumably the ferry will be out of service for some time, impacting the production goal, and will require repairs, impacting the labor goal.  Any time required for the response can also be considered an impact to the labor goal.

A Cause Map can begin as simply as beginning with an impacted goal and asking a couple of why questions.  In this case, the safety goal is impacted by the injuries, which were caused by the ferry striking the pier.  More detail can be added to the Cause Map by asking more “Why” questions.

In this case, it’s not clear what caused the crash, though drug or alcohol use by the captain has been ruled out.  There have been some recent complaints about maneuverability due to a recent overhaul replacing the engine and propulsion system but it’s not clear if this played a role in the crash.  It’s also unclear why the ship was traveling at 14 knots when it was about to dock.  Because the ship was about to dock, people had gotten up from their seats and were standing in hallways and on or near stairways, increasing the rate of injury.  It does not appear that there are any regulations requiring commuters to remain seated until the ferry has stopped moving.

The ferry company, as well as the appropriate transportation authorities, will continue their investigations to determine the causes of the ferry incident.  Once they do, they will provide recommendations or requirements to ensure a safer morning commute.

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

Over 60,000 Vehicles Recalled Due to Steering Column Defects

By Kim Smiley

General Motors Co has announced a recall of over 69,000 full-size trucks and vans because of steering column defects that may allow a parked car to roll away.  Only about 1 in 1,000 of the recalled vehicles is expected to have the defect.

This issue can be analyzed by building a Cause Map, or visual root cause analysis.    A Cause Map is an intuitive way to visually show the cause-and-effect relationships between the many causes that contribute to an issue.  In this example, the recall was announced because there are a large number of vehicles that need to be inspected.  The inspections are necessary because some vehicle need to have the steering columns replaced.  The replacements are necessary because a small percentage of vehicles have defective steering columns that may allow a parked car to roll.

Investigation into the steering column defects found that there were two separate issues causing similar problems.  There is a possibility that the column lock module assembly might malfunction because of a manufacturing issue with a component.  Investigators also found that some shift cables had been fractured because of mishandling.  Both issues resulted in the same potential safety issues.  If the steering column defects are present a parked car could roll away because it may be possible to shift from park when the key is removed or in “off” position, shift from park with application of brake pedal with key in “off” position, or to turn the key to the “off” position and remove while not in park.  To view a high level Cause Map of this issue which includes all these causes, click on “Download PDF” above.

Once the Cause Map is built, the final step in the process is to determine a solution to prevent recurrence.  Once the problems were identified the solution was fairly straightforward.  The recall was initiated to inspect all vehicles potentially affected by these issues and replace the steering column if a defect is found.

A recall is never a good thing for a company, but one silver lining in this incident is that the company identified the problem during an audit before receiving any reports of issues.  There have been no reports of accidents or injuries caused by these steering column defects.  The majority of the vehicles are also believed to be either in transit to dealers or sitting on dealer lots so a limited number of customers should be impacted by the recall.