By Kim Smiley
On June 13, 2013, an explosion at a chemical plant in Louisiana killed two and injured more than seventy others. The cause of the explosion is still unknown, but the federal Occupational Safety and Health Administration and the U.S. Chemical Safety Board are investigating the accident.
Even though the investigation is still ongoing, an initial Cause Map, or visual root cause analysis can be built for this issue. The initial Cause Map can document what is known at this point and can easily be expanded to incorporate more details as they become available. The first step in the Cause Mapping process is to fill in an Outline with the basic background information for the accident (such as the location, time and date) as well as document what overall goals were impacted by the incident.
In this case, the safety goal was obviously impacted because of the fatalities and injuries. The damage to the plant is an impact to the material goal and the time the plant is shut down is an impact to the schedule goal. Once the Outline is complete, including the impacts to the goal, the Cause Map is built by asking “why” questions. For example, we would ask “why” people were killed and injured and would add that there was an explosion at the chemical plant to the Cause Map.
What caused the explosion isn’t known, but every explosion requires oxygen, a spark and fuel so these basic facts can be added to the Cause Map. The plant housed a large amount of flammable material because it manufactures polymer grade propylene which is used to make plastics. If investigators are able to determine what created the spark that information could be added as well as any other relevant information that comes to light.
The Outline also has space to document anything that is different or unusual at the time of the accident. Anything unusual about the situation when the accident occurred is often a good starting point in an investigation because it may have played a role in the accident. In this example, the plant was being expanded at the time of the accident and there were many contract workers on site. If this is found to have played a role in the accident, this information would be incorporated onto the Cause Map as well as the Outline.
The final step of the Cause Mapping process is to use the Cause Map to develop solutions that can be implemented to help prevent a similar problem from occurring in the future. Once a final Cause Map is built that incorporates all the findings from the investigation, it will be helpful in understanding any lessons to be learned and discussing potential solutions.
To view a high level Cause Map and an Outline for this accident, click on “Download PDF” above.