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.