Monthly Archives: June 2014

Root Cause Analysis - Incident Investigation

Can a “Super Banana” Reduce Vitamin A Deficiency?

By Kim Smiley

Vitamin A deficiency is rare in developed countries, but it remains a major public health issue in more than half of all countries, particularly in especially in Africa and South-East Asia. Researchers at the Queensland University have created a “super banana” genetically engineered to contain alpha- and beta-carotene that they hope will reduce vitamin A deficiency in parts of the world where bananas are a staple crop.

The problem of vitamin A deficiency can be analyzed using a Cause Map, a visual format for performing a root cause analysis. A Cause Map is built by determining how an issue impacts the overall goals and then asking “why” questions and laying out the answers visually to show the cause-and-effect relationships. In this example, the overall goal of public safety is impacted because vitamin A deficiency causes 650,000 – 700,000 deaths and results in blindness in 250,000-500,000 children annually. This occurs because the body, especially growing bodies, needs vitamin A to function properly and the diet does not contain adequate vitamin A.

Bodies use vitamin A in a number of ways. For example, vitamin A is important for healthy vision and a lack of it will result in blindness.  It has been shown to play an important role in the immune system. Diets in some regions of the world lack enough vitamin A because they are poor subsistence-farming communities that predominantly consume locally grown crops and the local crops don’t contain sufficient vitamin A.

There have been a number of different ways to help reduce the occurrence of vitamin deficiency such as distribution of vitamins and introduction of new crops, but the problem of vitamin deficiency is still a widespread issue which led to the idea of genetically modifying local crops to be more nutritious. The idea behind the “super banana” is that they would look the same as other East African Highland bananas and grow in the same conditions, but that they would be enriched with additional nutrients. The inside of the “super bananas” is more orange than regular East African Highland bananas, but the outside looks the same.

Lab tests with gerbils have been successful and the first human trials of the modified bananas are scheduled starting this summer. If the human trials are successful, the next necessary step is for Uganda’s legislature to approve a bill allowing the crops to be grown. Researchers are hoping to have the modified bananas growing in Uganda by 2020 if the government approves the project.

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

Root Cause Analysis - Incident Investigation

Fingertips Amputated After Slip on Ice

By ThinkReliability Staff

Information on a slip that caused severe damage to an electrical contractor in Newcastle in August 2013 was recently released by Great Britain’s Health and Safety Executive (HSE). Though this incident didn’t make the front pages of the newspaper, it is representative of many of the injury investigations which we facilitate using the Cause Mapping method.

The first step in the Cause Mapping method of root cause analysis is to capture the what, when and where of the incident and the impacts to the organizational goals. In this case, the what (contractor slip and hand injury), when (August 30, 2013) and where (a moving conveyor at a baguette manufacturer in Leeds) are captured, as well as any differences and the task being performed at the time of the incident. There were two notable differences during the incident as compared to an “average” day that should also be noted: the safety guard had been removed from the conveyor and ice had accumulated on the floor. These differences may or may not be causally related to the incident. Additionally, the task being performed (cleaning up after contract electrical work) is captured as it, too, may be causally related to the incident.

The impacts to the goals are analogous to what stood in the way of a perfect day. A serious injury involving the partial amputation of two fingers and the injury of a third is an impact to the safety goal in this example. The £8,500 fine levied by the HSE is an impact to the regulatory goal. The worker had four weeks off work due to the injury, which is an impact to the labor goal. It is unclear if any other goals were impacted by this incident.

Once at least one impact to the goals has been determined, asking “why” questions helps us complete the second step, or analysis. In the analysis, we capture cause-and-effect relationships that map out the issues that led to the incident. In this case, the injury was caused by the contractor’s hand striking an unprotected drive chain on a moving conveyor. This occurred because the hand struck the area, the drive chain was unprotected, and the conveyor was moving. All three of these causes had to occur for the resulting injury.

The contractor’s hand struck the area because of a slip on an icy floor. Ice from an open freezer door (which appeared to be malfunctioning) had built up and had not been removed.   The drive chain was unprotected because the safety guard had been removed from the conveyor, which was moving likely due to normal operations.

According to Shuna Rank, the HSE inspector, “This worker’s injuries should not and need not have happened. This incident was easily preventable had Country Style Foods Ltd ensured safety guards were in place on the machinery. The company should also have taken steps to prevent the accumulation of ice on the freezer floor. Guards and safety systems are there for a reason, and companies have a legal duty of care to ensure they are properly fitted and working effectively at all times. Slips and trips are the biggest cause of major injuries in the food and drink industry with 37% of all major accidents in the industry being as a result of slips.”

The inspector’s quote clearly identifies the areas for improvement that could reduce the risk of similar incidents occurring. Namely, the manufacturer must ensure that damage resulting in ice buildup is fixed as soon as possible and that in the meantime, ice is regularly cleared away and the area is marked as a slip hazard. If a safety guard is removed for any reason, the conveyor should not be operating until it has been replaced properly. Ensuring that equipment is in proper working order is essential to reduce the risk to workers such as the injuries demonstrated in this case.

To view the Outline and Cause Map, please click “Download PDF” above. Or click here to read more.

Root Cause Analysis - Incident Investigation

Impact of Gasoline Spending on US Household Budgets

By Holly Maher

Having worked in an oil refinery for the majority of my career, the question “why is gasoline so expensive?” has been posed to me on more than a few occasions.  It is normally asked with a great deal of frustration and sometimes with a bit of anger directed at the oil companies (and those who work for them).  So, with summer driving season officially kicked off, it seems like an appropriate time to tackle this issue.

If we ask the question “What is the problem” we can expect to get different answers:  crude oil price is too high, oil companies are making too much profit, people are driving too many SUVs, etc..  All of these answers give perspectives on what different people view as the problem, which is subjective.  So in order to start the analysis, we have to identify how this issue is impacting our goals.  In terms of the impact to the average American family, the annual spending on gasoline is impacting the household budget.  In 2011, the average spending on gasoline was $2,655 or roughly 4% of the average household gross income.

Once we have identified the impact to the goal we can begin the analysis.  We start by asking “why” questions and documenting the answers to visually lay out all the causes that contributed to this impact.  The cause-and-effect relationships lay out from left to right.  The average annual spending on gasoline is caused by both the price of a gallon of gasoline, which in 2011 was $3.52/gal, as well as the annual consumption of gasoline (average household consumption was 754 gallons in 2011).  Although the national discussion tends to focus on the price at the pump, the price alone does not create the impact to the household budget (you don’t see too many articles on the price of a gallon of milk, which, by the way, in 2011 was $3.57/gallon).

The price of a gallon of gasoline is set by 4 primary causes:  crude oil price (~68% of the price), state/local/federal taxes (~13% of the price), transportation and marketing (~11% of the price) and the cost of refining the crude oil into useable products (~8% of the price). The price of crude oil in 2011 was $94.87/bbl (barrel).  This is compared to $27.39/bbl in 2000 and $23.19/bbl in 1990.  This price is set by normal supply and demand economics, both internationally and domestically.  The global demand for crude oil has dramatically shifted in recent years as the countries in eastern Asia have moved into their “industrial revolution”.  The supply of crude oil globally is set not only by total oil well capacity, but also by transportation availability, OPEC targets, as well as political sanctions on oil-producing countries.

In addition to normal supply and demand economics, crude oil is a traded commodity on the stock market and is susceptible to price fluctuation based on fear and speculation.  Prior to 2000, the energy market and trading of energy futures was regulated because of the significant impact it could have on the economy.  In 2000, the energy sector was deregulated as part of the Commodity Futures Modernization Act of 2000.

The average annual household consumption of gasoline in 2011 was 754 gallons.  This is caused by the annual miles driven per car (15,000 miles), the number of cars per household (1.95 cars), and the fuel efficiency of the cars.  The average mileage per car is caused by commute mileage, whether household members carpool, whether household members utilize public transportation and recreational miles driven (outside of work).  The fuel efficiency of cars is determined by the types of cars driven, the fuel efficiency technology available and the vehicle fuel efficiency standards required by law.  In 2011, 50% of the household vehicles purchased were classified as light trucks.  New fuel efficiency standards were introduced for vehicles in 2011 requiring passenger cars to meet 30.2 miles per gallon (mpg) and light-trucks to meet 24.2 mpg.  This was an increase of 2 mpg for each type of vehicle.

Once the analysis has been broken down into its causes, solutions can be identified to mitigate the impact to the goal.  Even with this initial, basic analysis, solutions start to be become visible. Household members could car pool more (with friends, co-workers, or their spouse).  Household members could take public transportation, if available, and communities could work to make public transportation more available to residents.  Households could purchase more fuel efficient vehicles. The government could continue to increase fuel efficiency requirements.  The government could pass a law re-regulating the energy sector.

As with any incident or problem with significant impact to the goal(s), the analysis always reveals more than one single cause.  Being able to see multiple causes gives us the opportunity to find more than one potential solution.

To view the Outline, Cause Map, and solutions please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Software Glitch in Electronic Voting System during Belgium’s Federal Election

By Kim Smiley

A root cause analysis of electronic voting – at the most basic level, the idea behind elections seems very simple – let every citizen vote one time and count them.  But in reality, it often proves difficult to quickly and accurately collect and count thousands and thousands of votes.   The recent software bug during the May federal elections in Belgium illustrates some of the technical difficulties that can come into play during an election.

Root Cause Analysis Cause Mapping of Belgiums voting system

Belgium held federal elections on May 25, 2014 and used an electronic voting system to collect and count many of the votes.  While computing election results, officials realized that some of the votes weren’t calculating correctly.  Announcement of the election results was delayed while the problem was addressed, but the bigger problem is that any software hiccups during elections make people question the validity of the vote.

A root cause analysis by Government officials have stated that the problem was quickly addressed and that the impacted votes would not have changed the outcome of the election, but the lack of transparency in the process worries some.  In fact, many countries have banned the use of electronic voting because of concern over potential issues and Belgium is one of the only European countries to still use e-voting machines.

There are two separate electronic voting systems in use in Belgium.  The software glitch impacted the older, first generation Jites system computers using DOS operating systems.  The Jites system was certified and tested, but the test program should be reevaluated before future elections because it missed a significant software glitch.  Another option would be to upgrade the first generation computers before the next election to reduce the risk of future issues by only having one system to test and maintain.

Conducting a large scale national vote is a tricky problem and worth pondering.  The system needs to be transparent enough that the public feels the system is “fair”, but secret enough that individual voters are ensured privacy.   Officials need to be able to ensure that only eligible voters participate, but need the process to not be so onerous that it inhibits citizens’ ability to navigate it (think the ongoing debate in the US regarding photo IDs).   There are a number of strong, opposing forces at play in the process and any issues like a software error only add fuel to the fire.

To view the Outline and the root cause analysis Cause Map, please click “Download PDF” above.  Or click here to read more.