Monthly Archives: February 2013

Root Cause Analysis - Incident Investigation

Engine Room Fire Results in Cruise Ship Nightmare

By Kim Smiley

On February 10, 2013, an engine room fire on the Carnival Triumph cruise ship knocked out a significant portion of the ship’s electricity and crippled the propulsion system.  Passenger descriptions of the rest of their “vacation” have included the words hellish and nightmare.

This incident can be reviewed by building a Cause Map, a visual format for preparing a root cause analysis.  A Cause Map intuitively lays out the causes that contributed to an issue to visually show cause-and-effect relationships.  The first step in building a Cause Map is to fill in an Outline which includes the basic background information for an issue as well as the ways that the problem impacts the goals.  In this example, a number of goals are impacted such as the customer service because of the many unhappy passengers and negative media coverage; the schedule goal because the delay of the return of the ship; and the safety goal because of there was a potential for illness.    Once the impacts to the goals are determined, the Cause Map is built by asking “why” questions.

Starting with the safety goal, the first step would be to ask “why” there was a potential for illness.  Illness was a very real possibility because of the unsanitary conditions that existed onboard the ship.  The toilets in the aft portion of the ship couldn’t be flushed because the sewage system was inoperable after the fire.  Full toilets and the rolling motion of the ship made a disgusting and unhealthy combination.  There have been many reports of human waste on floors and even leaking between levels onboard the ship which is probably not anybody’s idea of an ideal vacation setting.  Add in the limited electricity available after the fire and passengers faced filthy cabins without lighting or air conditioning.  Food also became an issue because the limited electricity made preparation of hot meals difficult and the supplies diminishing as the ship remained at sea longer than planned.  The ship’s return was delayed because it had to be towed back to port after the fire wiped out its propulsion.

Investigators are working to determine what caused the fire that started this mess.  They have determined that a leak in a fuel oil return line was part of the problem, but it may be months before the details are known.

What is known is that cruise ship fires aren’t as rare as might be expected.  There were reports of 79 fires onboard cruise ships from 1990 to 2011.   While more information is needed to understand the details of this particular fire, there has been speculation that lack of adequate preventative maintenance may contribute to this issue across the cruise industry.  Keeping a cruise ship in port for a week’s worth of maintenance costs tens of millions of dollars and companies have to try to balance this cost with the risk of an issue during operation.  And the risk is big.  If something goes wrong during operation, like it did in this example,  it can be very expensive.   The total cost of the fire onboard Carnival Triumph is estimated to be $80 billion, including 12 cruises that have already been canceled to allow time for repairs.  In addition the negative press isn’t exactly helping entice potential customers into booking a cruise.  Balancing the cost of maintenance with the risk of not performing it is an issue that many industries face.  No one wants to spend money on unnecessary maintenance, but no company wants to make headlines that have the word nightmare in them either.

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

Check out our previous blog about  the Costa Allegra , another cruise ship that lost power.

Root Cause Analysis - Incident Investigation

The Super Bowl Blacks Out in New Orleans

By Kim Smiley

The Super Bowl is always one of the most talked about television events of the year and this year the game was even more interesting than usual.  An impressive comeback attempt following a game delaying blackout made this one to remember.

The question of what caused the highly publicized blackout 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 fill in an Outline with the background information for the issue.  The goals that are impacted by an issue are listed on the bottom of the Outline.  In this example, the schedule goal is impacted because the Super Bowl was delayed; the material goal is impacted because a component called an electrical relay device needs to be replaced; and the customer service goal was impacted because the delay changed the momentum of the game significantly.    Individual fans may disagree, but the companies who have profits impacted by the Super Bowl probably consider the momentum shift a pleasant side effect of the blackout since the last 17 minutes of this game were the most watched.  Once the Outline is complete, the Cause Map is built by asking “why” questions.

Starting with the schedule goal, the next step would be to ask “why” the Super Bowl was delayed.    This happened because the game wasn’t able to be played because of a partial loss of power.  The electrical company has announced that a component called an electrical relay device failed, but the exact reason it failed hasn’t been determined.   Another cause that can be added to the Cause Map is that the backup power was insufficient to power the whole Stadium.  This cause is worth considering because a possible solution to this problem could be to add a more robust back up system to mitigate any future power issues.

The relay had been installed during major system upgrades that were performed during the previous two years to ensure that the stadium was ready for the demands of hosting the Super Bowl.  The relay was added to protect the Superdome electrical equipment if there was a cable failure between the incoming power lines (operated by the electric company) and the lines that run through the stadium.

This power problem is still being reviewed and it is still being determined if an independent review of the issue is necessary.  Once more facts are known, they can be easily incorporated into the Cause Map.  The final step in the Cause Mapping process would be to develop solutions that would help mitigate the issue and prevent future power failures.

See more power outage cause maps:

The Costa Allegra Loses Power

Power Outage Stretches from Arizona to California

Chile Power Outage 

Want us to cause map a specific power outage for you? Contact us at  info@thinkreliability.com and we’ll give you a “lights out” root cause analysis.

Root Cause Analysis - Incident Investigation

Brazilian Nightclub Fire Kills At Least 238 People

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By ThinkReliability Staff

A pyrotechnics display meant for outdoor use turned deadly at a band concert in a nightclub in Brazil on January 27, 2013.  The pyrotechnics – which were set off by the band – lit the soundproofing on the ceiling and it spread – with little help from non-functioning fire extinguishers.  The large crowd had difficulty leaving the club, which had only one exit blocked by bouncers who thought patrons were trying to leave without paying.

This tragic incident can be examined using a Cause Map, or visual root cause analysis, which visually diagrams all the causes and impacts related to the nightclub fire.  We begin with the impacted goals.  The safety goal was impacted due to the at least 238 people who were killed and 100 who were injured.  The severe fire is an impact to the environment.  People were unable to exit, which can be considered an impact to the customer service goal.  The loss of the use of the nightclub is an impact to the production goal, and the damage is an impact to the property goal.  Additionally, members of the band and owners of the nightclub are being held, potentially to be charged with manslaughter.  This can be considered an impact to the employee goal.

We begin developing cause-and-effect relationships by asking “Why” questions.  People were killed because they were in the nightclub, unable to exit and there was a severe fire.  Questions have been raised about why the nightclub was even in operation, as its licenses were expired.  People were unable to exit because there was only one exit – completely insufficient for a facility of this size and no windows in the bathroom.  Bouncers were blocking the only exit because they believed patrons were trying to leave without paying – nobody had told them of the fire.  Difficulty seeing the exits due to smoke and lost power resulting from the fire complicated matters even more.

The fire began when the pyrotechnics (heat) lit the soundproofing on the ceiling (fuel).  The fire was unable to be put out due to difficulties reaching the ceiling and non-functioning fire extinguishers.  Specific solutions are being debated by lawmakers in Brazil, but it is hoped that this tragedy will draw attention to – and improve – some of the conditions that contributed to this tragedy.

To view the Outline and Cause Map, please click “Download PDF” above.  Click here to read about another building fire.

 

Root Cause Analysis - Incident Investigation

The Dreamliner’s Battery Nightmare

By Kim Smiley

On January 16, 2013, the Federal Aviation Administration issued an emergency directive grounding all Boeing 787 Dreamliners operated by United States carriers during the investigation into two recent battery fires.  This emergency grounding is an unusually extreme step, especially given that the Dreamliner is a new plane with only six operated by US carriers at this time.

This issue can be analyzed by building a Cause Map, an intuitive, visual format for performing a root cause analysis.  A Cause Map is built by determining how the issue affects the goals of an organization and then asking “why” questions to find the causes that contributed to the problem.  In this example, the schedule goal is impacted because the Dreamliners have been grounded.  Why?  The Dreamliners were grounded because there is a known fire risk because there were two battery fires onboard these airplanes nine days apart.  The fact that the Dreamliner is the first major airliner to extensively use lithium-ion batteries and that fires in these batteries are particularly dangerous also contribute to the problem.   Lithium-ion batteries were used because they are lighter than other batteries and lighter planes use less fuel.  Fires in lithium-ion batteries are dangerous because they are difficult to extinguish because oxygen is released as they burn, which feeds the fire.

Several other goals are also worth considering like the customer service goal which is impacted by the negative publicity generated by this issue and the safety goal because there is a potential for injuries.   The economic impact of this issue could also be very significant since each Dreamliner costs $200 million and there are 800 planes on order in addition to about 50 that were already in service that may need to be repaired.

The battery fires are still being investigated but the cause isn’t known yet.  It may be an issue with manufacturing or the design itself.  What is known is that the Dreamliner is a brand new design that incorporates many new elements such as mostly electrical flight systems, an airframe that uses composite materials and the use of the lithium-ion batteries themselves.  The design process was also different from previous Boeing designs with much of the work outsourced to a network of global suppliers and very tight deadlines.

As more information becomes available, the Cause Map can easily be expanded to incorporate it.  To view a high level Cause Map of this issue, click on “Download PDF” above.