Don’t Just Google It . . . Maps Error Leads to Wrong House Being Demolished

By Angela Griffith

Imagine coming “home” and finding an empty lot. That’s what happened in Rowlett, Texas on March 22, 2016. A tornado had previously damaged many of the homes in the area; some were slated for repairs, and some for demolition. The demolition company had plans to level the duplex at 7601 Cousteau Drive, but instead demolished the duplex at 7601 Calypso Drive.

An error on Google Maps has been blamed for the mistake but, as is typical with these types of incidents, there’s more to it than that. To ensure that all the causes leading to an incident are identified and addressed, it’s important to methodically analyze the issue. Creating a Cause Map, a form of root cause analysis that creates a map of cause-and-effect relationships is one way a problem can be analyzed.

The first step in the Cause Mapping process is to capture the what, when and where of an incident. Along with the geographic (where the incident occurred) and process location (what was being done at the time), it can be helpful to capture any differences about the situation surrounding the incident. In this case, “differences” would be anything out of the ordinary during the demolishing of the house at 7601 Cousteau/Calypso. The error on Google Maps (which pointed to the house which was mistakenly demolished) is one difference. Another difference is that the name of the street was not checked during the location confirmation. Other potential differences between this demolish job and other demolish jobs were that the same house number was present on both streets, in close proximity, and both houses experienced tornado damage. These differences may or may not be causally related – at this point, potential differences are just captured.

The next step is to capture the impacts to the organization’s goals as a result of the incident. These impacts to the goals become the first effects in the cause-and-effect relationships. In this case, there’s a potential for injuries (an impact to the safety goal) as a result of an unexpected demolition. The demolition of a house planned to be repaired is an impact to the environmental, customer service, and property goals. The demolition of the wrong house is an impact to the production/ schedule and labor/time goals.

The analysis begins with one of the impacted goals. Asking “why” questions develops cause-and-effect relationships. For example, the demolition of the wrong house was caused by the duplex at 7601 Calypso Drive being demolished while the duplex at 7601 Cousteau was planned for demolition. Because both of these facts (which can be verified with evidence) resulted in the wrong house being demolished, they are both connected to the cause of ‘demolition of wrong house” and joined with an “AND”.

Each cause on the map is also an effect. More detail can be added to the Cause Map by continuing to ask “why” questions. However, one cause may not be sufficient to result in an effect, so questions such as “what else was required?” are also necessary to ensure all causes are present on the map. In this case, the crew went to the wrong house because of an error on Google Maps, which was used to find the house. Per a Google spokeswoman, 7601 Cousteau was shown at the location of 7601 Calypso. This error has been identified as “the cause” of the incident. However, there were other opportunities to catch the error. Opportunities that were missed are also causes in the cause-and-effect relationship. While there was a site confirmation prior to demolition, only the street number (7601), lot location (corner lot), and tornado damage were confirmed. All three of these data points used to confirm the location were the same for 7601 Cousteau and 7601 Calypso.

What hasn’t been mentioned in the news but is apparent from looking at a (corrected) Google Map is that the house-numbering scheme of the neighborhood was set up for failure. 7601 Calypso is on the corner of Calypso Drive and Cousteau Drive, meaning a person could easily believe it was 7601 Cousteau. 7601 Cousteau is just a block away, on the corner of Cousteau Drive and an apparently unnamed alley. I can’t imagine it is the first time that someone has confused the two.

While it’s too late for 7601 Calypso Drive, Google Maps has fixed the error. Likely in the future this demolition company will use another identifier (or will mark the house while talking to the homeowners prior to the demolition) to ensure that the wrong house is not destroyed.

To view the Cause Map, as well as the updated Google Map, click on “download PDF” above.

DC Metro shut down for entire day after fire for inspections

By Kim Smiley 

A fire in a DC Metro tunnel early on March 14, 2016 caused delays on three subway lines and significant disruption to both the morning and evening commutes.  There were no injuries, but the similarities between this incident and the deadly smoke incident on January 12, 2015 (see our previous blog on this incident) led officials to order a 24-hour shutdown of the entire Metro system for inspections and repairs.

The investigation into the Metro fire is still ongoing, but the information that is known can be used to build an initial Cause Map.  A Cause Map is built by asking “why” questions and visually laying out all the causes that contributed to an incident.  Cause Mapping an issue can identify areas where it may be useful to dig into more detail to fully understand a problem and can help develop effective solutions.

So why was there a fire in the Metro tunnel?  Investigators have not released details about the exact cause, but have stated that the fire was caused by issues with a jumper cable.  Jumper cables are used in the Metro system to bridge gaps in the third rail, essentially functioning as extension cords.  The Metro system uses gaps in the third rail to create safer entry and exit spaces for both workers and passengers because of the potential danger of contact with the electrified third rail.  The third rail carries 750 volts of electricity used to power Metro trains and could cause serious injury or even death if accidently touched.

The jumper cables also carry high voltage and fires and/or smoke can occur if one malfunctions.  Investigators have not confirmed the exact issue that lead to this fire, but insulation failures have been identified in other locations and is a possible cause of the fire. (Possible causes can be added to the Cause Map with a “?” to indicate that more evidence is needed.)

One of the things that is always important to consider when investigating an incident is the frequency of occurrence of similar issues.  The scope of the investigation and possible solutions considered will likely be different if it was the 20th time an incident has occurred rather than the first. In this case, the fire was similar to another incident in January 2015 that caused a passenger death.  Having a second incident occur so soon after the first naturally raised questions about whether there were more unidentified issues with jumper cables.  The Metro system uses approximately 600 jumper cables and all were inspected during the day-long shutdown. Twenty-six issues were identified and repaired. Three locations had damage severe enough that Metro would have immediately stopped running trains through them if the extent of the damage had been known.

The General Manger of the DC Metro system, Paul J. Wiedefeld, is relatively new to his position and has been both praised and criticized for the shutdown.  Trying to implement solutions and reduce risk is always a balancing act between costs and benefits.  Was the cost of a full-day shutdown and inspections of all jumper cables worth the benefit of knowing that the cable jumpers have all been inspected and repaired?  At the end of the day, it’s a judgement call, but I personally would be more comfortable riding the Metro with my children now.

For the first time, autonomous car is at fault for a crash

By Kim Smiley

On February 14, 2016, the self-driving Google car was involved in a fender bender with a bus in Mountain View, California.  Both vehicles were moving slowly at the time and the accident resulted in only minor damage and no injuries.  While this accident may not seem like a very big deal, the collision is making headlines because it is the first time one of Google’s self-driving cars has contributed to an accident.  Google’s self-driving cars have been involved in 17 other fender benders, but each of the previous accidents was attributed to the actions of a person, either the drivers of other vehicles or the Google test driver (while they were controlling the Google car).

The accident in question occurred after the Google car found itself in a tricky driving situation while attempting to merge.  The Google car had moved over to the right lane in anticipation of making a right turn.  Sandbags had been stacked around a storm drain, blocking part of the right lane.  The Google car stopped and waited for the lane next to it to clear so that it could drive around the obstacle.  As the Google car moved into the next lane it bumped a bus that was coming up from behind it.  Both the driver of the bus and the Google car assumed that the other vehicle would yield.  The test driver in the Google car did not take control of the vehicle and prevent the car from moving into the lane because he also assumed the bus would slow down and allow the car to merge into traffic. (Click on “Download PDF” to view a Cause Map that visually lays out the causes that contributed to this accident.)

Thankfully, this collision was a relatively minor accident. No one was hurt and there was only relatively minor damage to the vehicles involved. Lessons learned from this accident are already being incorporated to help prevent a similar incident in the future. Google has stated that the software that controls the self-driving cars has been tweaked so that the cars will recognize that buses and other large vehicles may be less likely to yield than other types of vehicles. (I wonder if there is a special taxi tweak in the code?)

It’s also worth noting that one of the driving factors behind the development of autonomous cars is the desire to improve traffic safety and reduce the 1.2 million traffic deaths that occur every year.  The Google car may have contributed to this accident, but Google cars have so far generally proved to be very safe.  Since 2009, Google cars have driven more than 2 million miles and have been involved in fewer than 20 accidents.

One of the more interesting facets of this accident is that it raises hard questions about liability.  Who is responsible when a self-driving car causes a crash? The National Highway Traffic Safety Administration (NHTSA) recently determined that for regulatory purposes, autonomous vehicle software is a “driver” which may mean that auto manufacturers will assume greater legal responsibility for crashes.  NHTSA is working to develop guidance for self-driving vehicles, which they plan to release by July, but nobody really knows yet the impact self-driving cars will have on liability laws and insurance policies.  In addition to the technology issues, there are many legal and policy questions that will need to be answered before self-driving cars can become mainstream technology.

Personally, I am just hoping this technology is commercially available before I reach the age where my kids take away my car keys.

Heavy metal detected in moss in Portland

By Kim Smiley

Residents and officials are struggling to find a path forward after toxic heavy metals were unexpectedly found in samples of moss in Portland, Oregon. According to the U.S. Forest Service, the moss was sampled as part of an exploratory study to measure air pollution in Portland.  The objective of the study was to determine if moss could be used as a “bio-indicator” of hydrocarbons and heavy metals in air in an urban environment.  Researchers were caught off guard when the samples showed hot spots of relatively high heavy metal levels, including chromium, arsenic, and cadmium (which can cause cancer and kidney malfunction).  Portland officials and residents are working to determine the full extent of the problem and how it should be addressed.

So where did the heavy metals come from?  And how is it that officials weren’t already aware of the potential issue of heavy metals in the environment? The investigation into this issue is still ongoing, but an initial Cause Map can be built to document what is known at this time.  A Cause Map is built by asking “why” questions and visually laying out all the causes that contributed to the problem.  (Click on “Download the PDF” to view the initial Cause Map.)

Officials are still working to verify where the heavy metals are coming from, but early speculation is that nearby stained-glass manufacturers are the likely source.  Heavy metals are used during the glass manufacturing process to create colors. For example, cadmium is used to make red, yellow and orange glass and chromium is used to make green and blue glass. The hot spots where heavy metals were detected surround two stained-glass manufacturers, but there are other industrial facilities nearby that may have played a role as well.  There are still a lot of unknowns about the actual emissions emitted from the glass factories because no testing has been done up to this point.  Testing was not required by federal regulations because of the relatively small size of the factories.  If the heavy metals did in fact originate from the glass factories, many hard questions about the adequacy of current emissions regulations and testing requirements will need to be answered.

Part of the difficulty of this issue is understanding exactly what the impacts from the potential exposure to heavy metals might be.  Since the levels of heavy metals detected so far are considered below the threshold of “acute”,  investigators are still working to determine what the potential long-term health impacts might be.

A long-term benefit of this mess is the validation that moss can be used as an indicator of urban air quality.  Moss has been used as an “bio-indicator” for air quality since the 1960s in rural environments, but this the first attempt to sample moss to learn about air quality in an urban setting.  As moss is plentiful and testing it is relatively inexpensive, this technique may dramatically improve testing methods used in urban environments.

Both glass companies have voluntarily suspended working with chromium, cadmium and arsenic in response to a request by the Oregon Department of Environmental Quality.  The DEQ has also begun additional air monitoring and begun sampling soil in the impacted areas to determine the scope of the contamination. As officials gain a better understanding of what is causing the issue and what the long-term impacts are, they will be able to develop solutions to reduce the risk of similar problems occurring in the future.

Crane Collapse In High Winds Kills One in NYC

By Angela Griffith

A crane collapsed in New York City on February 5, 2016 killing one, injuring three, and damaging two city blocks. While an investigation is underway and the causes of the crane collapse have not yet been determined, the city has already implemented new rules to make crane operations safer. We can examine the potential cause-and-effect relationships that led to the issue in a Cause Map, or visual root cause analysis.

We begin by capturing the what, when and where of the incident within a problem outline. The crane collapse occurred February 5 at about 8:30 a.m. Anything that is different or unusual at the time of an incident should also be noted on the outline and an important difference on February 5 was the accelerating winds. The crane that collapsed was a crawler crane, and at the time of the collapse, workers were in the process of securing the crane because of the high winds. This was as expected. Says New York City Mayor Bill de Blasio, “The workers on Friday morning did not begin work on the site, but immediately seeing the winds, made the move to secure the crane, so their timing was appropriate. Upon arrival, they immediately determined the need to secure the crane.”

The impact to the goals as a result of the incident are also captured in the problem outline. In this case, the safety goal was impacted due to the death, as well as injuries. The environmental goal was impacted by water leaks resulting from damage. Customer service (looking at the citizens of New York City as customers) is impacted due to closures. Production is impacted because 418 additional cranes were secured as a result of the incident. Property impacts includes damage to the crane, as well as two city blocks. The labor goal was impacted because of the time required for the response and removal of the damaged crane. It’s also important to capture the frequency of similar events. OSHA reports it has investigated 13 fatal crane accidents in the last 5 years. (There was a crane collapse in New York City in 2008 that resulted in 4 deaths. Click here to see our previous blog on this topic.)

Once the impacts to the goals have been captured, the analysis begins with one of these goals, which is an effect. Asking “why” questions allows the development of cause-and-effect relationships. In this case, the fatality and injuries resulted from the collapse of a crane. It also resulted from people being in the area of the crane collapse. Both of these causes are required (the fatality and injuries would not have occurred if the crane had not collapsed, or if people had not been in the area) so they are listed vertically and joined with “AND”.

People were in the area where the crane collapsed because the area was inadequately secured. This is likely because construction workers were responsible for securing the area, as well as securing the crane. The reasons for the crane collapse are unknown. However, the investigation will look at human error, structural and equipment problems, and impacts from high winds. While the cause has not been determined, it is considered likely that the wind played a role. The crane was not yet secured, as the workers were in the process of attempting to secure it. It was not required to be secured because city regulations limit operation of cranes when wind is above 30 miles per hour(mph), or if there are gusts greater than 40 mph. The crane operators were working under a limit of 25 mph, as sometimes manufacturers use stricter limits. The forecast did not indicate that winds would be greater than 25 mph that day.

As a result of the incident, Mayor de Blasio put into place immediate and temporary rules regarding crane operation. These rules will be in place until a task force provides updated recommendations within 90 days. Uniformed personnel will assist with enforcing closures associated with crane use. Crane operations are limited to wind speeds less than 30 mph (or gusts up to 40 mph). A city sweep and increased fines were also put into place to ensure the updated regulations are followed.

To view a one-page overview of the Outline, Cause Map and interim solutions, click on “Download PDF”.