Neurotoxin makes California crabs unsafe to eat

By Kim Smiley

California officials have delayed indefinitely both recreational and commercial fishing for Dungeness and Rock crab from the coast north of Santa Barbara all the way to the Oregon border because the crabs have been determined to be a threat to public safety.  Testing has shown that many of the crabs in this region contain potentially unsafe levels of domoic acid, a powerful neurotoxin, that can cause illness in humans if they consume the crabs. Domoic acid poisoning causes vomiting, diarrhea, cramping and can even lead to brain damage and death in severe cases.  Scientists are continuing to test crabs caught off the California coast and the hope is to open crabbing season if/when the crabs are found to be safe for consumption.

A Cause Map, a visual root cause analysis, can be built to help understand the causes that contribute to this issue.  The first step in building a Cause Map is to understand the impacts from the issue being considered.  Obviously this issue has the potential to impact public safety because the crabs have the potential to cause illness, although no cases of domoic acid poisoning in humans have been reported in this year. The economic impact to the fishing industry from the delay in the start of crabbing season is also very significant.  California’s crabbers typically gross about $60 million a year and many families depend on the money made during crab season to live on throughout the year.  This issue also impacts the environment because humans aren’t the only animals that can suffer from domoic acid poisoning and other creatures are continuing to eat the contaminated crabs.  Sea lions in particular have been affected by the neurotoxin and many have died.  Removing large predators has the potential to significantly impact the entire ecosystem.

The Cause Map itself is built by asking “why” questions and laying out the answers to intuitively show the cause-and-effect relationships. So why do the crabs have high levels of domoic acid in their bodies?  This year off the coast of California, warmer than typical ocean temperatures have led to an unusually large and long-lasting algae bloom created by Pseudo-nitzschia. Domoic acid is naturally produced by Pseudo-nitzschia and it can be concentrated into dangerous levels as it moves up the food chain.  Small fish and shellfish such as krill, anchovies and sardines consume the domoic acid along with the algae.  Crabs eat the smaller creatures that have been contaminated with domoic acid.  Crabs can eventually excrete the domoic acid, but the process is slow and takes enough time that the domoic acid can build up to high levels in the bodies of the crabs.  If bigger creatures such as humans and sea lions eat the contaminated crabs, they can be poisoned by the domoic acid that was initially produced by the algal bloom.  There is nothing that can make the contaminated crabs safe for consumption. Neither cooking nor cleaning can eliminate the risk of poisoning from the neurotoxin so the only safe option is to wait until the domoic acid returns to safe levels in the crabs.

To view an Outline that lists the impacted goals and see a high level Cause Map of this issue, click on “Download PDF” above.

High School Open Flame Chemistry Demonstration Ends in Injuries

By Kim Smiley

Six were injured, two seriously, in an accident involving an open flame chemistry demonstration at a high school in Fairfax County, Virginia on October 31, 2015.  At the time of the incident, the teacher was performing a well-known experiment to show the students how different chemical elements can change the color of a flame. According to students present in the classroom, the teacher was in the process of adding more flammable liquid to the experiment when a splash of fire hit students and the teacher.

A Cause Map, or visual root cause analysis, can be used to analyze this incident.  The first step in the Cause Mapping process is to fill in an outline to document all the basic background information for an incident such as time, date, and location.  Additionally, how the incident impacts the organization’s goals is listed on the bottom of the outline.  For this example, the safety goal is clearly impacted by the injuries, but there are several other impacts that need to be considered as well such as the damage to the classroom, evacuation of the school and required emergency response.  Fairfax County has also banned all open flame experiments pending a thorough investigation of this issue which can be considered an impact to the regulatory goal.

Once the Outline is complete, the Cause Map itself is built by asking “why” questions beginning with one of the impacted goals. Starting at the safety goal in this example, the first step would be to ask “why” were 6 people injured?  These injuries occurred because people were burned because there was an uncontrolled fire in a classroom, people were near the fire and no protective gear was worn.  (When there is more than one cause that contributes to an effect, the cause boxes are listed vertically and separated by “and” to show that all causes were required.)  No information has been released to the public about why the students were sitting so near the open flame experiment without any type of safety barrier or why protective gear wasn’t worn, but these are both branches of the Cause Map that should be expanded during a complete investigation.  If the same fire had occurred, injuries may have been prevented or at least been less severe if the students were farther away from the flames or if they had protective gear on to protect them from burns.  It’s important to understand why the experiment was performed as it was in order to develop solutions that could prevent injuries in the future.

There has been a little information released about why the fire was uncontrolled during the experiment.  Eyewitnesses have stated that the teacher was adding more fuel to the fire because it was starting to burn out.  As liquid fuel was added, the fire spread unexpectedly and burning fuel splashed out of the experiment location onto students and the teacher performing the experiment.  The specific details of what occurred during this specific fire have not been released and should be looked at during the detailed investigation.  Once more information is known, the Cause Map could be easily expanded to incorporate it.

The Chemical Safety Board (CSB) is not investigating this incident, but has stated that it is gathering information on it.  The recent accident appears to be similar to three accidents involving open flame experiments that injured children during an 8 week period in 2014.  These three accidents all involved experiments using flammable liquid, a flashback to the bulk containers of fuel and fire engulfing members of the audience.  Following the 2014 accidents, the CSB issued a safety bulletin titled “Key Lessons for Preventing Incidents from Flammable Chemicals in Educational Demonstrations”.   Key lessons listed from the CSB safety bulletin that should be considered when planning open flame experiments are as follows:

– Do not use bulk containers of flammable chemicals in educational demonstrations when small quantities are sufficient.

– Implement strict safety controls when demonstrations necessitate handling hazardous chemicals – including written procedures, effective training, and the required use of appropriate personal protective equipment for all participants.

– Conduct a comprehensive hazard review prior to performing any educational demonstration.

– Provide a safety barrier between the demonstration and audience.

Are Your Vehicle’s Tires Safe?

By ThinkReliability Staff

Four vehicle accidents between February and May of 2014 took 12 lives and injured 42 more. While the specifics of the accidents varied, all four were due to tread separations on tires. Later that year the National Transportation Safety Board (NTSB) hosted a Passenger Vehicle Tire Safety Symposium to address areas of concern regarding passenger vehicle safety due to tire issues. A special investigation report, which was adopted October 27, 2015, provides a summary of the issues and industry-wide recommendations to improve passenger vehicle safety.

There are multiple issues causing safety concerns with tires, and multiple recommendations to mitigate these safety risks. When dealing with a complex issue such as this, it can help to visually diagram the cause-and-effect relationships. We can do this in a Cause Map, or visual root cause analysis. This analysis begins with an impact to the organization’s goals. According to the NTSB report, tire-related accidents cause more than 500 deaths and 19,000 injuries every year in the US. Customer service (customers being members of the public who purchase and/or use tires) is impacted due to a lack of understanding of tire safety. The regulatory goal is impacted due to a lack of tire registration, and the production goal is impacted due to a low recall completion rate. Lastly, the property goal is impacted due to tires that are improperly maintained.

Cause-and-effect relationships are developed by beginning with an impacted goal (in this case, the deaths and injuries) and asking “why” questions. In this case, the deaths and injuries are due to tire-related accidents, of which there are about 33,000 every year in the US. Tire-related accidents includes accidents that are due to tire issues (such as tread separation) caused by improper maintenance or an unrepaired manufacturing issue with a tire (specifically those resulting in a tire recall). While the NTSB is recommending the promotion of technology that may reduce the risk of tire-related accidents, they also made recommendations that can reduce the risk of these accidents in the near term.

From 2009-2013, there were 3.2 million tires recalled in 55 safety campaigns. However, 56% of recalled tires remain in use, because of very low recall work completion rates. In a typical tire recall, only about 20% of recalled tires are returned to the manufacturer. (In comparison, about 78% of recalled cars are repaired.)   Many tires aren’t registered, and if they aren’t, it’s difficult to reach owners when there are recalls. Independent dealers and distributors, which sell 92% of tires in the US, aren’t required to register tires. While it is possible for consumers to look up their own tires to determine if they’ve been recalled, it’s difficult. The full tire identification number may not be printed in an accessible location, and the National Highway Traffic Safety Administration (NHTSA) website for tire recalls was found to be confusing.

The NTSB has recommended that tire manufacturers include the full tire identification number on both the inboard and outboard side walls of each tire so it can be more easily found by consumers. The NTSB has also recommended that the NHTSA, with the cooperation of the tire industry and Congress, if necessary, improve its recall site to allow search by identification number or brand and model, and improve registration requirements and the recall process.

Regarding improper maintenance, the report found that 23% of tire-related crashes involved tire aging and that 50% of drivers use the wrong tire inflation pressure, 69% have an underinflated tire, 63% don’t rotate their tires, and 12% have at least one bald tire. The report found that consumers have an Inadequate understanding of tire aging and service life and recommends developing test and best practices related to tire aging, and developing better guidance for consumers related to tire aging, maintenance and service life.

The NTSB has issued its own Safety Alert for Drivers, which includes the following guidance:

– Register new tires with the manufacturer

– Check your tire pressure at least once a month

– Inflate your tires to the pressures indicated in your vehicle owner’s manual (not on the tire sidewall)

– When checking tire pressure, look for signs of damage

– Keep your spare tire properly inflated and check it monthly for problems

– Rotate, balance and align your tires in accordance with your vehicle owner’s manual

– If you hear an unusual sound coming from a tire, slow down and have your tires checked immediately

To view the Cause Map, including impacted goals and recommendations, click on “Download PDF” above. Or, click here to read the NTSB’s executive summary.