Monthly Archives: August 2014

Root Cause Analysis - Incident Investigation

Ice Bucket Challenge Ends in Serious Injuries

By Kim Smiley

In a terrible reminder that awful things can happen at any time, two firefighters were seriously injured helping the Campbellsville University’s marching band raise money for amyotrophic lateral sclerosis (ALS) research by participating in the trendy ice bucket challenge.  If you ever log onto Facebook, you are probably already familiar with the concept behind the ice bucket challenge, but in case you are not a social media fan, the idea behind the ice bucket challenge is that friends tag each other to either donate $100 to an ALS-related charity  or dump a bucket of ice water over their head.  If you choose the ice bucket, you are supposed to take a video or photo as evidence and post it online.

Trying to create an entertaining video of the ice bucket dumping is part of the fun for many of the participants.  In order to make a memorable video to post on social media, the firefighters that were injured used a fire truck ladder to dump ice water on the band from above.  While on the ladder, the firefighters were near high voltage power lines (although they never actually touched the lines) and electricity arced out, injuring four firefighters.  Two firefighters were treated and released, but two were still hospitalized days later.  One was listed as stable, but the other was in critical condition.

This accident clearly illustrates that high voltage can be extremely dangerous even if you don’t touch the equipment. An arc flash can occur when a flashover of electric current leaves its intended path and travels through the air from one conductor to another or to the ground.  The closer a person is when an arc happens, the more dangerous it is.  Arcs are exceptionally hot and can cause very serious injuries and even death from several feet away when high voltage is in use.

The Public Service Commission stated that they will investigate the location to ensure that the power line had the correct clearance from the ground, trees and structures, but initial reports do not indicate any problems with the power poles.  Possible solutions that could be used to reduce the risk of a similar problem in the future are increased education on the risks of high voltage and ensuring that adequate warning signs are in place.

These have been the most dramatic injuries associated with the ice bucket challenge, but there are a slew of videos featuring buckets dropped on heads, slips and a variety of other unintended outcomes that look painful.  If you are considering doing the ice bucket challenge, please remember that a gallon of water weighs over 8 pounds.  A five gallon bucket filled with water is pretty heavy.  Think the plan through carefully before you ask somebody to dump water on you off a balcony because it may end badly.

Root Cause Analysis - Incident Investigation

Freight Trains Collide Head-On in Arkansas

By Kim Smiley

On August 17, 2014, two freight trains collided head-on in Arkansas, killing two and injuring two more.  The accident resulted in a fire after alcohol spilled from a damaged rail car ignited, prompting evacuation of about 500 people from nearby homes.  The trains were carrying toxic chemicals, but none of the cars carrying the toxic chemicals are believed to have been breached during the accident.

The National Transportation Safety Board (NTSB) is currently investigating this accident, but an initial Cause Map, or visual root cause analysis, can still be built to help document and illustrate the information that is known.  One of the benefits of a Cause Map is that it can easily be expanded to incorporate information as it becomes available.  The first step of the Cause Mapping process is to fill in an Outline with the basic information for an incident.  In addition, anything that was different at the time of accident is listed.  How the incident impacts the overall goals is also documented on the bottom of the Outline.

Like many incidents, there are a number of goals that were impacted by this train collision.  The safety goal is obviously impacted by two fatalities and injuries.  The property goal is impacted because of the significant damage to the trains and freight.  The labor/time goal is impacted because of the response effort and investigation that are required as a result of the accident. Potential impacts or near misses should also be documented so the potential release of toxic chemicals is considered an impact to the environmental goal.

The second step is to perform the analysis by building the Cause Map.  To build the Cause Map, start with one impacted goal and ask “why” questions.  Each answer is added to the Cause Map.  Each impacted goal should be considered and the cause boxes should all connect at some location on the Cause Map.  Starting with the safety goal in this example, the first question would be: why were two people killed?  This occurred because there was a train collision.  The trains collided because they were traveling toward each other on the same track.  No details have been released about how the trains ended up on the same track.  The trains’ daily recorders (which provide information about the trains’ speed, braking and throttle) have been found and will be analyzed by investigators. The NTSB has stated that they will be looking into a number of factors such as the train signals and fatigue since the accident occurred late at night.

The final step in the Cause Mapping process is to develop solutions that can be implemented to reduce the risk of a similar problem recurring in the future.  Since the investigation is ongoing, talk of solutions is premature at this point.  Once more is known about the causes that contributed to this issue, the lessons that are learned can be used to develop solutions.

Root Cause Analysis - Incident Investigation

Will Factory Explosion Lead to Increased Safety?

By ThinkReliability Staff

On August 2, 2014, 75 workers were killed and about 186 were injured by an explosion at an auto parts factory in Kunshan, China. This devastating event has raised questions about worker protection and oversight in China, as well as the responsibility for manufacturers using subcontractors in China to provide a safe workplace.

The explosion can be examined in a Cause Map, or visual root cause analysis, to look at the effects, causes, and potential solutions of the issue. A Cause Map visually diagrams the cause-and-effect relationships associated with an issue. The first step in the Cause Mapping process is to determine the impact on an organization’s goals. In this case, the goals will be looked at from the broader perspective of the country of China. The safety goal was impacted due to the large number of fatalities and injuries. The regulatory goal is impacted due to the five executives that were detained (though it’s unclear for what purpose they are being held). In the wake of the disaster, 268 factories in the surrounding area have been shut down (impacting the production goal) as part of a three-month round of inspections (an impact to the labor goal).   In addition, the property goal was impacted due to the damage to the factory, the full extent of which is still unknown.

The cause-and-effect relationships resulting in these impacts to the goals are developed by asking ‘Why’ questions. The fatalities, injuries and damage to the factory resulted from an explosion. Preliminary investigation shows that it was a metal dust explosion. Dust explosions require five components to occur (as described in the dust explosion pentagon). These components are: heat, fuel, oxygen, confinement and dispersion. Oxygen and confinement are present under normal conditions. The preliminary investigation has identified a spark as the heat source (a common potential heat source in industrial settings).

In the case of a dust explosion, the fuel source is a dust, which is distributed into the air, providing a high level of surface area allowing the fuel to become explosive (dispersion). The process being performed at the plant, which manufactures wheels for a car manufacturer, was electroplating/ polishing hubcaps. At the time, the workers were polishing hubcaps, a process that is known to create metal dust that can lead to dust explosions if safety regulations aren’t carefully followed. Specifically, safety regulations protecting against dust explosion involve cleaning and ventilation. The preliminary investigation found a shortage of equipment that is used to remove dust.

Unfortunately, that’s not too surprising. Industrial accidents kill tens of thousands of people a year in China, which has generally demonstrated a lack of regard for safety. Regulations involving dust are insufficient (and insufficiently enforced) by both the government and the manufacturing companies that subcontract work to Chinese firms (and generally outsource oversight to their contractors). Subcontractors who make small, low-value parts find themselves under heavy pressure to cut costs in a competitive market. According to Geoffrey Crothall of the China Labor Bulletin, “The explosion at the factory in Kunshan illustrates once again that although there are many laws and regulations outlining health and safety standards in the workplace those standards are not properly enforced by local authorities.”

In response to the explosion, China has detained executives from the company, and has closed 268 factories that have the potential for similar issues until they are given government permission to reopen. The government is conducting what is expected to be a three-month round of investigations of these factories and is expected to develop regulations that will better protect workers from explosive dust conditions.

The incident is drawing comparisons to the Triangle Shirtwaist Company fire in New York City which killed 146 workers in 1911. After the deadly fire, many protections were put into place that have increased workplace safety in the United States. It is hoped this tragedy will lead to a similar outcry that will force the government to act on increasing worker safety and produce lasting change.

To view the Outline and Cause Map based on the preliminary investigation, click on “Download PDF” above. Or, click here to learn more about dust explosions.

 

Root Cause Analysis - Incident Investigation

Software Glitch Delays U.S. Travel Documents

By Kim Smiley

The Consular Consolidated Database (CCD) is the global database used by the U.S. State Department to process visas and other travel documents.  On July 20, 2014, the CCD experienced software issues and had to be taken offline.  The outage lasted several days with the CCD being returned to service with limited capacity on July 23.  The CCD is huge, one of the largest Oracle-based warehouses in the world, and is used to process a hefty number of visas each year and the effects of the software glitch have been felt worldwide.  The State Department processed over 9 million immigrant and non-immigrant visas overseas in 2013 so a delay of even a few days means a significant backlog.

This issue can be analyzed by building a Cause Map, a visual root cause analysis.  A Cause Map visually lays out the different causes that contribute to an issue so that the problem is better understood and a wider range of solutions can be considered.  The first step in the Cause Mapping process is to define the problem, which includes documenting the overall impacts to the goal.  Most problems impact more than one goal and this example is no exception.

The customer service goal is clearly impacted because thousands – and potentially even millions – have had their travel document processing delayed.  The negative publicity can also be considered an impact to the customer service goal because this software glitch isn’t doing the international image of the U.S. any favors.  The delay in travel document services is an impact to the production/schedule goal and the recovery effort and investigation into the problems impact the labor/time goal.  Additionally, there are potential economic impacts to both individuals who may have had to change travel plans and to the U.S. economy because these issues may discourage international tourism.

The next step in the Cause Mapping method is to build the Cause Map.  This is done by asking “why” questions and using the answer to visually lay out the cause-and-effect relationships.  The delay in processing travel documents occurred because the CCD is needed to process them and the CCD had to be taken offline as a result of software issues.  Why were there issues with the database? Maintenance was done on the CCD on July 20 and the performance issues began shortly thereafter.  The maintenance was done to improve system performance and to fix previous intermittent performance issues. The State Department has stated that this was not a terrorist act or anything more malicious than a software glitch.  An investigation is currently underway to determine exactly what caused the software glitch, but the details have not been released at this time.  It can be assumed that the test program for the software was inadequate since the glitch wasn’t identified prior to implementation.

The final step in the Cause Mapping process is to identify solutions that can be implemented to reduce the risk of a problem recurring.  Details of exactly what was done to deal with the issue in the short term and bring the CCD back online aren’t available, but the State Department has stated that additional servers were added to increase capacity and improve response time.  There is also a plan to improve the CCD in the longer term by upgrading to a newer version of the Oracle database software by the end of the year which will hopefully prove more stable.

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