By Kim Smiley

A coal mine explosion in Amaga, Colombia on June 16, 2010 has left at least 18 dead, 1 injured and at least 53 people unaccounted for, and presumed dead.  The deaths and injuries resulted from a fireball caused by an explosion.

Every explosion is caused by four factors: heat, fuel, oxygen and confinement.  In this case, the fuel was methane gas that had built up in the mine.  Methane is naturally produced as a byproduct of coal mining.  The methane was not removed from the mine because the mine lacked a methane ventilation pipe.  Additionally, the workers at the mine did not realize that methane levels were high because there was no gas detection system at the mine.

The number of dead and missing is so high because more people than usual were at the mine – the explosion happened during shift change.  Rescue efforts have been delayed by the high levels of gas in the mine, further increasing the number of deaths.

By clicking “Download PDF” above, you can view the thorough root cause analysis built as a Cause Map in a simple, intuitive format that fits on one page.

Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.