By Mark Galley

While battling a fire in a mansion in Hollywood Hills, California on February 16, 2011, a firefighter was killed (and 5 others seriously injured) when the roof collapsed.  As a result of the firefighter’s death, the owner/ architect of the home was convicted of involuntary manslaughter.  He is scheduled to serve 6 months and then will be deported.

The fire wasn’t arson, but the owner/ architect was considered responsible due to the installation of an outdoor-only fireplace on the top floor of his home.  Because of the legal issues surrounding this case, it’s important to carefully determine and clearly present all of the causes that led to the fire and the firefighter’s death.

We can capture information related to this issue within a Cause Map, or visual root cause analysis.  A Cause Map begins with the impacted goals, allowing a clear accounting of the effects from the issue.  The firefighter’s death is an impact to the safety goal, as are the injuries to the other firefighters.  Impacts to the safety goal are the primary focus of any investigation, but we will capture the other impacted goals as well.  In this case, the regulatory goal was impacted due to the non-compliant fireplace, the non-compliance being missed during inspection, and the prison sentence for the architect/owner.  Additionally the loss of the home and the time and effort put into firefighting and the subsequent trial impact the property and labor/time goals.

Once the impacts to the goals are determined, asking “why” questions begins to develop the cause-and-effect relationships that resulted in those impacts.  A Cause Map can start simple – in this example, the safety goal was impacted due to the death of a firefighter.  Why? Because the ceiling collapsed.  Why? Because the house was on fire.  Why? Because heat ignited flammable building materials.

Though this analysis is accurate, it’s certainly not complete.  More detail can be added to the Cause Map until the issue is adequately understood and all causes are included in the analysis.  Detail can be added by asking more “why” questions – the heat ignited flammable building materials because an outdoor-only fireplace was improperly used inside the house.  Causes can also be added by considering causes that both had to occur in order for the effect to happen.  The firefighter was killed when the ceiling collapsed AND the firefighter was beneath the ceiling, fighting the fire.  Had the ceiling collapsed but the firefighters not been inside, the firefighter would not have been killed by the ceiling collapse.

Detail can also be added between causes to provide more clarify.  In this case, the ceiling collapse was not directly caused by high heat.  Instead, the high heat activated and melted the sprinkler system, resulting in a buildup of water that caused the ceiling collapse.  The other goals that were impacted should also be added to the Cause Map, which may result in more causes.  In this case, the improperly installed fireplace was missed by the building inspector, which is an impact to the regulatory goal.  The reason it was missed was debated during the trial, but changes to the inspection process may result that would make this type of incident less likely, ideally reducing the risk to firefighters and home owners.

An incident analysis should have enough detail to lead to solutions that will reduce the risk of recurrence of the impacted goals.  As I mentioned previously, solutions from the perspective of the building inspectors may be to look specifically for issues on fireplaces that could lead to these types of fires.  Ideally, a way to determine if a sprinkler system was malfunctioning and leading to water collection could be developed that could reduce the risk to firefighters.  For homeowners, this incident should stand as a reminder that outdoor-only heat sources such as fireplaces are outdoor-only for a reason.