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.
Dear Sirs, the number of people died in this tragedy was 238 so far (there are about 50 people still in the hospitals). So, please correct the title of the article.