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”.