By Kim Smiley

On December 19, 2013, 76 people were injured when a large section of plaster fell from the ceiling of London’s historic Apollo Theatre.  Luckily there were no fatalities as a result, but six people were seriously injured in the accident.

The investigation is still underway, but an initial Cause Map can be built to begin analyzing the incident.  The first step in the Cause Mapping process is to fill in an Outline with the basic background information as well as formally list how the incident impacts the goals so that no part of a multifaceted problem is neglected.  It’s important to understand how an issue impacts all goals, such has safety issues, financial considerations, schedule delays, etc. There are times when different solutions can help mitigate risks to separate goals so it is useful to list all impacted goals for clarity.   Listing the impacted goals will also help focus the investigation on the most important elements.

Another very important part of the Outline is a space where any relevant differences are listed.  Anything that was different at the time an incident occurred is usually a good place to start digging during an investigation.  For this example, there was heavy rain during the hour preceding the ceiling collapse.  It’s also worth noting that the Apollo Theatre is 112 years old.

Investigators have not announced what led to the ceiling collapse, but early speculation is that rain water leaked through the roof and settled onto the plaster.  The theory is that the additional weight from the water was more than the ceiling could handle and it fell, taking a lighting rig and part of a balcony with it.   If this was the case, there will need to be hard questions asked about the adequacy of current building codes and inspection requirements.  Currently, the roof on the Apollo Theatre was only required to be inspected every 3 years.  It appears that the Theatre was up to date on and had passed all required inspections so the required periodicity may need to be re-evaluated in light of the recent failure.

Any suspected causes that haven’t been proven yet can be included on the Cause Map, but are marked with a “?” to indicated that they need additional evidence.  This helps document what has been considered during an investigation and questions that still need to be answered.

To view an Outline and the initial Cause Map of the Apollo Theatre ceiling collapse, click on “Download PDF” above.