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.