Sea life Devastated by Molasses Spill

By Kim Smiley

On September 9, 2013, a reported 1,400 tons of molasses was inadvertently spilled into Honolulu Harbor in Hawaii, devastating the sea life.   When I think of ocean spills, pictures of oil-covered animals jump into my mind, but the molasses spill is proving to be potentially just as damaging to the environment.

This incident can be analyzed by building a Cause Map, an intuitive format for performing a root cause analysis.  A Cause Map visually lays out the causes that contribute to an accident to show the cause-and-effect relationships between them so that it’s easier to understand the factors that led to the issue.  Understanding all the causes and not just focusing on a single “root cause” helps broaden the potential solutions that are considered and can lead to a better long term solution. The first step in the Cause Mapping process is to define how the problem impacted the goals and then these impacts are used as the starting point for the Cause Map.

The most obvious impact from the molasses spill is that thousands of fish and other marine life were killed.  They suffocated because the molasses sank and displaced the oxygen- containing seawater in the harbor.  The density of molasses is what makes this spill so different from an oil spill.  Oil is lighter than water and floats on top of the ocean while molasses sinks to the bottom, with devastating effects at all levels in the ocean.  Divers investigating the molasses spill reported that there were no signs of life in the ocean near the spill; all bottom dwellers had been killed.

The fact that molasses sinks also means that there is no practical way to clean it up.  One positive about molasses is that molasses, unlike oil, will mix with water. It sits on the bottom until it is diluted and ocean movements disperse it.  Since the spill occurred in a protected harbor, the ocean movements are weaker and the time frame to move the molasses is longer than it would be in the open ocean, but nature will eventually return oxygen levels in the harbor to life-supporting levels.

The cause of the spill has been reported to be a leaking pipe.  Molasses produced on Hawaii was being pumped into a ship for transportation to the mainland where it was planned for use in animal feed.  During the transfer, the molasses was accidently pumped through a pipe with a leak and nobody noticed before the majority of the molasses had been released into the harbor.  Details about what specifically caused the leak haven’t been released.

There are also other impacts from the spill that are worth considering.  With any environment issue, the cost of the investigation and any clean up that needs to be done is always substantial. Many businesses in the area were also impacted by a drop in tourism because the harbor was closed for about two weeks after the accident and normal tourism levels will probably not return until marine life in the area begins to recover.  There was also a potential safety risk to any swimmers for a time after the accident because the presence of thousands of dead fish could attract predators.

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

Is Your Emergency Response Plan Really Good Enough?

By Kim Smiley

The deadly shooting at the Washington Navy Yard this week hit especially close to home.  I live about 15 miles away from the Navy Yard and I also worked there for 5 years.  And my husband, a Navy civilian, still does.

As far as the thousands impacted by the shootings, my family was very lucky.  My spouse came home safely while others did not.  Additionally, we hit the jackpot from a logistics stand point because he was in his office (which is not in the affected building) when the order to shelter in place was issued.  He had access to his phone and internet (as well as a bathroom and his packed lunch).   I had word almost immediately that he was safe and was able to communicate with him throughout the day.  When word came that he could go home but his car couldn’t, we were able to coordinate and get him home as quickly as possible.

Like many people across the country, I was riveted by the news and was holding my breath as the information fluctuated by the hour.   At ThinkReliability, we are generally called in to help investigate or document information after an incident so the opportunity to watch an incident as it plays out in real time is fairly rare.  I was throwing together a makeshift family emergency response as I was bombarded with calls and messages from concerned friends and family as well as trying to figure when and how my husband would get home.  And for somebody who works on processes and solutions for a living, my personal emergency response wasn’t very impressive.  Take my word for it: the ideal time to discover your mother in-law has your old cell phone number isn’t when your husband’s place of employment just made national headlines.

A time like this is an excellent opportunity to review both your organization and family’s emergency response plan.  Is your organization ready to handle a shelter-in-place situation?   Do you know which authorities to contact in case of emergencies?  And, one piece that I think is often overlooked: how you would handle the flow of information?  How do you pass word to families if something significant occurs and do people know where to look for the information?  Would you post the information on the website?  Would an old-fashioned phone tree serve your needs?  Do you have updated contact information and home phone numbers?

It’s also important to have a basic plan in place for your family in case something unforeseen happens.  There was a flurry of activity on Monday as everyone worked to make sure that there was a plan for all the children of the people we knew on the Navy Yard to be picked up and potentially kept overnight.  Thousands of people work on the Navy Yard and there were several cases were a single parent or both parents were stuck on lock-down for an indeterminate amount of time. Are you really ready to handle a situation like that?  If your family or employees have any special needs, like requiring medication, I would recommend making a plan to deal with it.   I also highly recommend taking a moment to make sure that any list with people allowed to pick up your children is up to date and includes a few folks who do not work in your building or even on the same side of town.  Fairly simple precautions can make a tough situation go much smoother.

And don’t think you don’t need a basic plan if you have no dependents.   Do you know how you would get home if you suddenly had to leave your car at work like many of the Navy Yard employees did?  What if your wallet was left behind in a rushed evacuation?  It might be a good idea to have enough money to cover cab fare in your car or in your badge holder if you wear one to work.  How do you pass word to your parents that you’re okay, especially if you don’t have access to a phone?  Would your mom think to check her email?  Do you have a friend who has your parents’ or siblings’ phone numbers and could call them for you if they aren’t comfortable with social media or computers?  Trust me; your families would be very interested in hearing that you’re okay.

I hope you never experience any crisis even remotely close to the tragedy at the Navy Yard.  But if there is ever an emergency, you’ll be grateful if you made a plan beforehand.

NYT Website Disrupted for Hours

By Kim Smiley

On Tuesday, August 27, 2013 the New York Times website went dark for several hours after being attacked by a well-known group of hackers.   Reports of hacked websites are becoming increasingly common and the New York Times was just one of many recent victims.

A Cause Map, or visual root cause analysis, can be used to analyze the recent attack on the New York Times website.  A Cause Map lays out the many causes that contribute to an issue in an intuitive format that illustrates the cause-and-effect relationships.   A Cause Map is useful for understanding all the causes involved and can help when brainstorming solutions.  To see a Cause Map of this example, click on “Download PDF” above.

Some details of how the attack was done have been released, as documented on the Cause Map. The New York Times website itself was not technically hacked, but traffic was redirected away from the legitimate website to another web domain.   To pull off this feat, hackers changed the domain name records for the New York Times website after acquiring the user name and password of an employee at the domain name registrar company.  The employee inadvertently provided the information to the hackers by responding to a phishing email asking for personal information.

The email sent by the hackers looked legitimate enough to fool the employee.

So why did hackers target the New York Times in the first place?  The answer is that the New York Times is one of many western media outlets to be targeted by Syrian Electronic Army (S.E.A.), who has claimed responsibility for the attack.  The S.E.A. supports President Bashar al-Assad of Syria and is generally unhappy with the way the events in Syria have been portrayed in the West.

So the next logical question is how do you protect yourself from a phishing scheme?  The first step is awareness.  Pretty much everybody who uses email can expect to receive some suspicious emails.  A few things to look out for:  attachments, links, misspellings, and a mismatched “from” field or subject line.  Also any alarming language should be a red flag.  For example, an email from your credit card company warning you that your account will be closed unless you take immediate action is probably not the real deal.  A good rule of thumb is to never respond to any email with personal information or to click on links in emails. If you think a request for action may be real, either call the company or open a new web browser window and type in the company’s web address.  It’s best to delete any suspicious emails immediately.

This example is also a good reminder to be aware that websites can get hacked.  A great example of this is when the S.E.A. hacked the Associated Press’s twitter feed last April and used it to announce (falsely) that the White House had been bombed.  That one tweet is estimated to have caused a $136 billion loss in the stock markets as people responded to the news.  In general, it is probably good to be skeptical about anything shocking you read online until the information is confirmed.

What Happens When a Copy Isn’t a Copy?

By Kim Smiley

Think of how many documents are scanned every day. Imagine how important some of these pieces of paper are, such as invoices, property records, and medical files. Now try to picture what might happen if the copies of these documents aren’t true copies. This is exactly the scenario that Xerox was recently facing.

It recently came to light that some copies of scanned documents were altered by the scanning process. Specifically, some scanner/copier machines changed numbers on documents. This issue can be analyzed by building a Cause Map, an intuitive, visual format for performing a root cause analysis. The first step in the Cause Mapping process is to fill in an Outline with the basic background information on an issue. Additionally, the impacts to the overall goals are documented on the Outline to help clarify the severity of any given issue. In this example, the customer service goal is impacted because the scanners weren’t operating as expected. There is also a potential impact to the overall economic goal because the altered documents could result in any number of issues. There is also an impact because of the labor needed to investigate and fix the problem.

After completing the Outline, the next step is ask “why” questions to build the Cause Map. Why weren’t the scanners operating as expected? This happened because the scanners were changing some documents during the scanning process. Scanners use software to help interpret the original documents and Xerox has stated that the problem happened because of a software bug. Testing showed that the number substitutions were more likely to occur when the settings on the scanners were set to lower quality/ higher compression because of the specific software used for these settings. Testing also showed that the error was more likely to occur when scanning those documents that were more difficult to read such as those with small fonts or that had already been copied multiple times.

Xerox had been aware of the potential for number substitution at lower quality settings, but didn’t appear to expect it to occur at factory settings (which was found to be very unlikely, but possible). A notice that stated that character substitutions were possible appeared on the scanners when lower resolution settings were selected and was included in some manuals, but this approach seems to have been ineffective since many users were caught unaware by this issue.

After a Cause Map has been built with enough detail to understand the issue, it can be used to help develop solutions. In this example, Xerox developed a software patch that corrected the error. Xerox also posted several blogs on their website to keep customers informed about the issue and worked with users to ensure that the patch was successful in correcting the error.

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