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Root Cause Analysis - Incident Investigation

Emergency Plan Could Have Saved Lives in TX Plant Explosion

by ThinkReliability Staff

Investigations are still ongoing to determine details on what caused the April 17, 2013 explosion in West, Texas (the subject of a previous blog).  The death toll has risen to at least 14, including 10 emergency workers.  Around 200 are believed to be injured.  The deaths were caused by the explosion of the site AND the proximity of the victims to the site.  The emergency workers were on-site fighting a fire (which was the ignition source of the explosion), but many of those injured had no real reason to be in such a proximity that they would be injured.   

Warning systems and emergency notifications may have resulted in some of the non-emergency response victims getting out of harm’s way.  However, warning systems and notifications like those required for other industrial sites including oil refineries and chemical plants are not required at fertilizer plants.  The plant owner did not comment on emergency management plans for the site.  Senator Barbara Boxer of California will attempt to determine if those requirements need to be strengthened. 

However, even if a warning system had provided sufficient protection to keep nearby citizens from harm, the property damage would have been extensive.  Many properties – including homes and schools – nearby were severely damaged in the blast.  This has led some to believe that there should be an enforced geographical buffer between these types of industrial facilities and other types of facilities, like homes and schools.  The mayor of West has suggested that the plant be rebuilt away from populated areas. 

More and more concerns are being raised about the safety of the plant itself – and the safeguards that could have prevented this explosion.  Despite the large amount of potentially explosive ammonium nitrate stored at the plant, the plant did not have a sprinkler system or fire barrier (which may have prevented the fire from igniting the fertilizer).   

Industrial plants such as these are regulated by a host of state and federal agencies, including the Environmental Protection Agency (EPA).  The EPA required a worst-case scenario from the West site, which identified a release from an anhydrous ammonia storage tank.  The risk of fire or explosion, and the storage of ammonium nitrate were not identified in the scenario, provided in 2011.  (The facility was fined in 2006 for not filing its risk management plan.) 

A key concern is the amount of fertilizer (270 tons) that was stored at the site – which was not disclosed with local governments or federal agencies.  Ammonium nitrate can be used as an explosive (~2.4 tons were used in the Oklahoma City bombing in 1995).  The high volume of ammonium nitrate was not known or disclosed to local or federal officials.   

Most of the victims in this incident were first responders – who had reported to the fire, not knowing the risk they were taking.  The facility had not disclosed the dangers on site, had not provided adequate protection from fire, and had provided little in the way of an effective emergency response plan.   

Every industrial site should have an up-to-date risk/emergency management plan.  The plan needs to be updated whenever new hazards are brought on-site or identified.  It is crucial that these plans be developed and shared with local response organizations, such as fire-fighters, so that they can be prepared for any potential issues.  These plans should also include community engagement to provide necessary information to people in the area as to what actions should be taken.  Existing incident investigations for industrial incidents can be used as a basis for creating these plans.  But, you don’t need to wait until you have a problem at your facility.  Taking the lessons learned from disasters that have already taken place can save your facility – and your community – a tot of heartbreak.   

Remember: A smart man learns from his mistakes, but a wise man learns from others’ mistakes. 

Root Cause Analysis - Incident Investigation

Contaminated Water Issues Remain at Fukushima

by ThinkReliability Staff

High levels of contaminated water leaving the highly damaged reactors at the Fukushima Daiichi nuclear power plant in Japan are creating issues for the personnel on site, who are working frantically to keep the reactor safe and working towards decommissioning and closing down the site.  Additionally, there is continued concern for the ongoing safety of the site, as the high volume of water could potentially threaten the safety of the reactors.

We can look at these issues in a Cause Map, or visual root cause analysis.  With a Cause Map, the first step is to determine how the issue impacts the organization’s goals.  In this case, we can consider the goals from the perspective of the utility company that owns the power plant.  There is an impact to the safety goal because of the potential risk for another accident, according to the Chairman of the Nuclear Regulatory Authority.  The leakage of contaminated water is an impact to the environmental goal.  There is concern about the lack of a comprehensive plan by the utility, which can be considered an impact to the customer service goal.  The massive construction efforts required to install tanks to store the water are an impact to the property goal and the efforts by the workers to control the flow are an impact to the labor goal.

Once the impacts to the goals have been determined, the next step is asking “Why” questions to determine the cause-and-effect relationships that led to the incident.  In this case, the issues resulting in the high rate of contaminated water needing to be stored are that high rates of water are entering the reactor, becoming contaminated due to the damage inside the buildings from the earthquake and tsunami on March 11, 2011, and the water has to be removed from the building.

The water is entering the buildings because the plant is in the groundwater flow path from the mountains to the ocean and there is insufficient protection to prevent the water accessing the plant.   Severe cracking in the reactor buildings from the earthquake/tsunami are unable to be repaired due to the high residual levels of radioactivity.  The utility rejected plans to build a wall to protect the reactor.  It is believed this is because the utility had planned to dump the water into the ocean.   Additionally, according to the Japan Atomic Energy Commission, the issues from the water weren’t something that were thought of, as the focus was on the nuclear issues.  All involved in the cleanup, including the utility, have had their hands full, so it’s likely something as benign-seeming as water just wasn’t on the list of immediate concerns.

The contaminated water must be pumped out of the building to avoid swamping the cooling systems, which are still needed to remove decay heat that continues to be produced even after the reactors are shut down.  It appears that the original plan was to filter the water and dump it into the ocean, but even after filtering, a high level (about one hundred times the level released from a healthy plant) of tritium would remain.  Public outcry has ended the possibility of being able to dispose of the water that way.  Wastewater pits originally built for this purpose were found last month to be leaking, necessitating the installation of hundreds of tanks for water storage.

For now, the utility workers continue to install tanks to hold the radioactive water.  The task is so overwhelming, it’s not clear if there are any other plans to try and slow the tide of contaminated water.  However, outside experts are attempting to provide assistance.  The International Atomic Energy Agency completed its initial review of the decommissioning plans last month.  The final team report is expected later this month.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause Analysis - Incident Investigation

Hundreds of Garment Workers Killed in Building Collapse

By ThinkReliability Staff

Hundreds are confirmed dead – with hundreds more still missing – as a result of a building collapse in Bangladesh.  The number of people who were in the building when it collapsed is unclear, due to spotty records.  Some sources have suggested the death toll may surpass 1,000.

We can examine the causes that led to the deaths in a Cause Map, which visually diagrams the cause-and-effect relationships that led to the tragedy.  First, we capture the impacts to the goals, which includes the extremely significant impact to the safety goal due to the high number of deaths as well as many other goals, including compliance, production and the impact to the labor goal resulting from the rescue and recovery operations.

The deaths were caused by the collapse of a building which was partially occupied at the time. The building housed five garment factories, as well as a bank and other shops.  Even though cracks appeared in the building   and inspectors requested evacuation and closure of the building, garment workers were ordered back to work.    The bank was evacuated, and the shops were already closed.  Despite deplorable conditions (brought to the attention first by a building fire last November and now by this tragic collapse),  workers (mainly young women)   can still be found to work in the garment industry because the average wages in the country are so low.  Eight people, including the building owner and engineers, have been charged as a result of the collapse.

The building, which was illegally built 3 stories too high, was not up to code and not approved by the government.  The building was built on wetland and used substandard materials for construction. As a result of this collapse, the government has said it will form a committee to ensure the safety of buildings and workers.  Shops in the US and Europe that sell garments produced in Bangladesh have distanced themselves from the companies housed in the buildings while many consumers call for more oversight from these companies, who utilize cheap labor in Bangladesh to create their goods.  The garment industry accounts for 77% of Bangladesh’s exports.

It is hoped that this recent tragedy will increase the attention paid to worker safety by the government within Bangladesh as well as consumers who buy the end product abroad.

To view the Outline and Cause Map, please click “Download PDF ” above.

Root Cause Analysis - Incident Investigation

The 8 Worst Typos Ever Made

By ThinkReliability Staff

When we perform a root cause analysis, we occasionally find that something as seemingly minor as a typo has had a huge impact on an organization’s bottom line, their reputation, or even public safety.  The following is a collection of some of the worst typos ever made, with respect to impacts to the organization’s goals.

8. Misspelling your own name 

The Oops: In 2008, a New Hampshire newspaper misspelled its own name, in the front page title, specifically by adding an extra “s”.  Missouri State University misspelled its own name on bags provided to students (Univeristy [sic]).  The error was pointed out by a student.  However, the most well-known of this kind of error probably occurred when “Chile” was misspelled on their 50-peso coin.  The misprinting occurred in 2008, but was not noticed until late 2009.  (Rather than CHILE, the coin said “CHIIE” [sic].  The coins are now collectors’ items.)

The Impact:  The general  manager of the Chilean mint was fired for the coin error.  In the newspaper and university cases, actual cost was minimal and the main impact was abject embarrassment.  However, typos can frequently result in loss of opportunities.  Some recruiters have said that when they get multiple submissions for a single job, resumes with errors go straight to the shredder.

7. Counting on a computer to do your job for you 

The Oops: On January 7, 2009, the US Army admitted that 7,000 letters addressed “Dear John Doe” were sent out to family members of soldiers killed in Iraq.

The Impact: The Army immediately issued a formal apology and sent a personal note to the families.  The letters were sent to the correct families, but there must have been a devastating moment for the families when they thought they may have received someone else’s letter . . . and then realized they hadn’t.

6. Entering the wrong number 

The Oops: On February 5, 2011, an employee at a company in Japan listed 610,000 shares of a job recruiting company at 1 yen apiece.  What it really meant to do was list 1 share at 610,000 yen (~$5,000).  A surprising number of similar stories abound, including a listing on April 5, 2006 for flights from Canada to Cyprus for $39 CAD, instead of $3,900.

The Impact: Although the company in Japan tried to cancel the order, it was processed by the Tokyo Stock Exchange, resulting in a loss of $225 million.   In the case of the surprisingly cheap airline tickets, they were honored by the airline (after initially trying to cancel the tickets) to 500-2000 people, resulting in a very expensive typo indeed.

5. Incorrect punctuation 

The Oops: A communications company in Canada thought it had a five-year deal beginning in spring 2002 with a utility company to add cable lines to thousands of utility poles.  Then the utility company cancelled in early 2006.  The Canadian Radio-television and Telecommunications Commission determined that, because of an extra comma, the contract said that the contract could be cancelled with one-year’s notice, even during the first five years.  (The area in question said the contract: “shall continue in force for a period of five years from the date it is made, and thereafter for successive five year terms, unless and until terminated by one year prior notice in writing  by either party.”)  A missing hyphen in the coded computer instructions was partially responsible for the loss of steering on Mariner 1, which was launched on July 22, 1962.

The Impact: After the cancellation, the utility upped its rates for the use of the poles, which will result in the communications company paying about $2.13 million more than it thought.  But if you think that’s expensive, even worse was the loss of Mariner 1, which had to be blown up when it could no longer be steered.  The value of the Mariner 1 in 1962 was $18.5 million.

4. Using the wrong units 

The Oops: The Mars Climate Orbiter was lost on September 23, 1998 while trying to establish orbit around Mars.  Turns out the trajectory was lower than expected (allowing the orbiter to be subjected to the extreme heat of the Martian atmosphere) because incorrect velocity changes were used in calculations.  Specifically, results from a software program were provided in pound force (English System of Units) and the program predicting the velocity assumed the results were  in Newtons (International System of Units, or SI), a factor of difference of 4.45.  (Read more about the Mars Climate Orbiter.)

The Impact: The Mars Climate Orbiter was destroyed with a complete loss of mission.  The orbiter cost $125 million in 1998.

3. Leaving out a (very important) word 

The Oops:  The interesting thing about some small words (like “not” or “out”) is that they change the meaning of the entire sentence.  A man named Bruce Wayne Morris (who does not become Batman) was sentenced to death in 1987 after the jury was given the choice of death or prison for life with the possibility of parole.  The choice was in fact between execution or a life sentence without parole.

The Impact: Morris’ death sentence was reversed by a federal appeals court in 2001 – that’s right, 11 years later.  (The cost of 11 years worth of deliberation and appeals is not known.)  It is thought that the jury originally opted for the death sentence rather than worrying about him being released on parole at some point in the future.

2. Checking the wrong box 

The Oops:  On January 28, 2013, Evan Spencer Ebel was released from jail, the result of a clerical error.  In 2008, while serving eight years, Ebel pleaded guilty to assaulting a prison guard.  The additional sentence was to be served after the original eight-year sentence.  Instead, the record indicated that the second sentence was to be served concurrent with the original sentence.

The Impact: Ebel is believed to have murdered a pizza delivery man on March 17 and the executive director of the state Department of Corrections on March 19 before he was killed by deputies in Texas on March 21.  A similar situation also ended in tragedy when Charles Anthony Edwards III was mistakenly discharged  in January 2012 from a high-security mental hospital in California, where he is suspected of fatally stabbing a shop owner.

1. Writing illegibly 

The Oops:  While bad penmanship may not necessarily be considered a typo, it can result in the same kinds of problems.  Bad penmanship means that the person who has to read it is much more likely to read it incorrectly.  In one such case, the registration for a ship’s Emergency Position Indicating Radio Beacon (EPIRB) was written sloppily, and a “C” become a “0”.  This didn’t much matter until more than two years later, on March 24, 2009, when the ship (Lady Mary) began to sink and set off its EPIRB.  Because the code was entered incorrectly, it took more than an hour and a half to locate the ship.

The Impact: By the time the Lady Mary was reached (the delay was due to other compounding errors as well), only one crew member was able to be saved.  The other six men were lost at sea.

What to do so this doesn’t happen to you 

When something is important, give it an extra edit.  Specifically, find someone who is not a coworker (a coworker will likely gloss over the same things you did, like the name of your organization).  Motivated teenagers make great editors.  Offer them a dollar for every error they find.  (It’s well worth it.)

Note that legal documents, given the importance of their exact wording and difficulty changing any whoopsies, should be extra, extra carefully edited.

If you really don’t have time to get an independent edit, try reading it out loud.

When your computer is doing some of the work for you, it’s probably a good idea to actually look at a few of the results.

When you’re working with numbers, which are much more difficult to check for errors than words (“univeristy” [sic] is not a word, but 39 is still a number), perform a related math calculation.  One that in particular could have come in handy here is the percentage reduction in the cost of the item.   (Plane tickets at 99% off?  Maybe you want to look at that one again.)

Also, your math teachers weren’t kidding about always using units with your numbers.  Or else you might as well answer the question “How far is it?” with “10”.  If at any point in your analysis a different unit of measurement comes up, go ahead and write both, the way many cookbooks and measuring cups now contain both ounces (English System of Units) and milliliters (Metric System of Units).

All the editing tips above may help, but maybe more important is an understanding of the possible impact of a seemingly innocuous typo.  Yes, they happen to everyone.  But before you let them out of your office, take another look.  If someone thinks you’re wasting your time, show them the two million-dollar examples above.

I’ve made a handy sheet to remind you why you care about editing.  To take a look and print it out for your wall, please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Deadly Explosion at Texas Fertilizer Plant

By ThinkReliability Staff

An explosion at a fertilizer plant in West, Texas, destroyed much of the town and killed between 5-15 people.   (Search and rescue is still ongoing.)  At least 160 were injured but that number may increase.  The material involved in the explosion was ammonium nitrate, a popular fertilizer.

Capturing the impacts to the goals as a result of an issue is essential to understanding the true effect.  In this case, the fatalities and injuries were severe.  The property damage, which included the plant, as well as the homes of more than 100 families, was also extensive.  An environmental impact resulted from the release of ammonia, which is a respiratory irritant. There was some level of evacuation, which can be considered an impact to the customer service goal, though the high number of injuries has led some to believe the evacuation was not widespread enough.  Additionally, ongoing search and rescue, and firefighting operations are an impact to the labor goal.

These goals were all impacted due to the explosion at the fertilizer plant.  Ammonium nitrate can explode when ignited at very high temperatures.  In this case, a fire provided the high heat.  We can capture these causes in a Cause Map, or a visual form of root cause analysis.  The cause of the fire itself is as yet unknown, though if that is determined we can add it to the Cause Map as well.

What is known is that efforts to prevent explosion were ineffective.  The plant did not believe that an explosion was possible.  Its internal safety review had a worst-case scenario of a ten-minute ammonia release, causing no injuries.  It is fairly rare that ammonia nitrate explodes; only 17 known cases of unintended ammonia nitrate explosions resulting in fatalities have occurred since 1921.  Firefighters were on scene fighting the fire when the explosion occurred, leading to many responder fatalities and injuries.  Oversight at the facility was limited; OSHA has not inspected the facility for at least the last five years.

It is worth exploring why large amounts of ammonium nitrate were present.  Ammonium nitrate is an inexpensive, effective fertilizer.  It is particularly good at delivering nitrogen to food-bearing plants, like fruit trees.  The use of nitrogen greatly increases the yield of food from these plants.  (It is said to increase the carrying capacity, or number of people who can be supported by a hectare of land – from 1.9 to 4.3.)  Given the shortage of food-growing land, this is certainly important.   However, the benefits must be considered alongside the risk and certainly in the future more oversight of these types of facilities may be needed to protect the public from the process as they benefit from the results.

To view the Outline and Cause Map, please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Seat Belts: A Simple Solution That is Still Underused

By ThinkReliability Staff

One of the most frequent questions we get is “What’s the root cause?”  The problem with that question is that there is never just one, root cause.  Rather, the ‘root cause” should be thought of as a system of causes, much like the roots of most plants are a system.  But the idea of a root cause is attractive – only one thing to find, analyze and solve.  There are a few, rare situations that are almost one, root cause.  One of them is the use of seat belts.

Not wearing a seat belt can cause all kinds of problems, in any kind of vehicle.  In passenger vehicles, seat belts saved more than 75,000 lives from 2004 to 2008, according to the National highway Traffic Safety Administration (NHTSA).  Over that same period, more than 26,000 more lives WOULD have been saved if everyone wore a seat belt.  Unfortunately, not everyone does.  According to the National Safety Council (NSC), seat belt use varies by the type of vehicle but is around 80%.

It’s not just cars that are at issue.  On March 29, 2013, a man was thrown from an experimental plane and killed when the canopy came off.  He wasn’t wearing a seat belt, which would have almost certainly kept him from being ejected – and killed.  Although the FAA requires that safety belts be fastened while crewmembers are at their duty  stations, the pilot, who was killed, had unfastened his safety belt to troubleshoot problems with the battery and apparently did not successfully re-fasten the belt.   (The instructor was not ejected and was able to safely land the plane.)

Although states are trying with mandatory seat belt laws, you can’t force everyone to wear a seat belt all the time.  However, there are many actions being taken to try and increase seat belt use.  As previously mentioned, states are increasing laws and enforcement of requiring seat belt use for all passengers.  Car manufacturers have added warning systems that encourage seat belt use for drivers, and front seat passengers.

Seat belt use (percentage-wise) is lowest among those who have just gotten their license.  As a parent, requiring use of a seat belt every time, every trip, for every passenger can help reduce the risk to your child and his or her passengers.  As an employer, vehicle crashes can have a serious impact to your organization. According to the Occupational Safety and Health Administration (OSHA), motor vehicle accidents are a leading cause of death and injury and cost employers $60 billion annually.  All employers should have a driver safety program.   (Tips on establishing a driver safety program can be found here.)

There is no question that deaths from traffic accidents are a major concern – to everyone.  According to the NHTSA, “seat belts are the most effective traffic safety device for preventing death and injury.”  Because of the effectiveness of seat belts, the  risk of deaths from vehicle accidents, it’s no stretch to say that buckling your seat belt – and getting everyone in your vehicle, family, and organization to do the same – may well be the most important thing you do today.

To view the Outline and Cause Map for the plane ejection, please click “Download PDF” above.  If you’re curious why school buses do not have seat belts, read our previous blog.  Or click here to  read more:

This incident

NHTSA

NSC

FAA

OSHA

Root Cause Analysis - Incident Investigation

8 Marines Killed During Training Exercise With Live Ammunition

By ThinkReliability Staff

Eight Marines were killed, and seven Marines and sailors were injured, as the result of the unexpected explosion of a 60 mm round inside a mortar tube during a live ammunition training exercise.  While details are still to be determined, it is known that the unexpected explosion of a mortar round led to the deaths and injuries of those participating in a training exercise with a 60 mm round inside a mortar tube.

Though details of the incident are still unknown, we can begin a Cause Map, or visual root cause analysis, diagramming possible causes which remain to be investigated.  As more information becomes available, evidence supporting or excluding potential causes is included on the Cause Map.

We capture the What, When and Where of the incident in the Problem Outline.  In this case, a training accident/ explosion occurred on March 18, 2013 at about 10:00 pm at the Hawthorne Army Depot in western Nevada.  At the time, a mountain training exercise with live ammunition was using a 60 mm round inside a mortar tube.  A traffic accident that may be related has been mentioned in the news, but no detail has been provided.  To ensure that this line of inquiry is followed during the investigation, we can include it in the “different, unusual, unique” line of the problem outline.

Data that is known, such as the types of damage resulting in deaths and injuries, is included with supporting evidence, in this case testimony of the hospital spokesman.  Causes still to be determined, such as whether the mortar round exploded prematurely in the tube, detonated after being fired, or whether more than a single round exploded are included with question marks and joined by “OR”.  When evidence is obtained throughout the investigation related to a given cause, it is included directly beneath the cause it controls.  Along with the unknown method of detonation of the round, it is unknown whether an issue with the firing procedure, a malfunctioning firing device, or a malfunction in the explosive mortar is to blame.

More details should be coming soon since the use of 60 mm mortars is suspended until the review of this incident determines what happened.  At that time, those causes ruled out by evidence can be crossed off (but left on the Cause Map so that others know they were considered and ruled out as more evidence became available).

At that time, solutions that best address the issues that were causally related can be brainstormed, evaluated, and implemented.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause Analysis - Incident Investigation

Hindenburg Crash: The Importance – and Difficulty – of Validating Evidence

By ThinkReliability Staff

Since the Hindenburg explosion in 1937, theories have abounded on what caused the leaking gas and spark that doomed the airship and dozens of passengers.  We discussed some of these theories in our previous blog on the Hindenburg disaster.

In December, 2012, a documentary on the Discovery Channel used new evidence to discuss the most likely cause of the disaster.  Yep, that’s right.  76 years after the original explosion, evidence is still being gathered to help determine what really caused the explosion that killed 36 people.

Sometimes evidence is relatively easy to gather – many pieces of equipment now feed into automatic data collectors, which can provide reams of data about what happened for a specific period of time.  Sometimes, however, evidence is much harder to come by. This is especially the case with fires or explosions which frequently destroy much of the available evidence.

When evidence is hard to come by, it is difficult to determine the exact cause-and-effect relationships that led to an incident.  The best we may be able to do is capture different possibilities in a Cause Map, or visual root cause analysis, and leave the causes that haven’t been validated by evidence as possible causes, indicated by a question mark.

Sometimes, determining the exact cause(s) is important enough to result in painstaking efforts like those performed by a team at the South West Research Institute.  The team created three 1/10-scale models, not a small undertaking when the scale models are over 80 feet in length and is inflated with 200 cubic meters of hydrogen.  They then replicated scenarios described by the various theories by setting fire to, and blowing up, the models.  Additionally, they studied archive footage and eyewitness accounts to increase their understanding of the disaster.

As a result, the team now believes they have determined what happened.  Says Jem Stansfield, an aeronautical engineer and the project lead, “I think the most likely mechanism for providing the spark is electrostatic.”   The spark ignited leaking hydrogen, caused by a broken tensioning wire that punctured a gas cell or a sticking gas valve.

View the updated investigation with the recently released evidence incorporated by clicking “Download PDF” above.

Read our detailed writeup on the Hindenburg investigation.

Or, click here to read more from the blog of the on-air historian and technical advisor to the project (some really cool photos of making and destroying the models are included).

Root Cause Analysis - Incident Investigation

Natural Gas Explosion Kills One in Kansas City

By ThinkReliability Staff

A natural gas leak at a business plaza in Kansas City was reported to the Fire Department just prior to 5 pm on February 19, 2013.  However, the area was not evacuated until just prior to an explosion that left 1 dead and 15 injured.  The leaking gas was not shut off until 3 hours after the report.

The causes that resulted in this tragedy can be examined within a Cause Map, or visual root cause analysis.  The analysis begins by determining which goals were impacted in a problem outline, which captures the what, when and where of the incident, as well as the impact to the goals.  In this case, the safety goal was impacted due to the fatality and injuries.  The environmental goal was impacted due to the natural gas leak and the customer service goal was impacted due to an ineffective evacuation.  (How do we know it was ineffective?  Because people were still present in a building that exploded due to a gas leak that was known for almost an hour, although the timing of the ordered evacuation is not known.)  Additionally, the property goal was impacted due to the destruction of restaurant, which was the site of the explosion, and damage to adjoining properties.  Lastly, the labor goal is impacted due to the investigation by state utility regulators, which is expected to take months of painstaking work to add detail to the causes which are already known.

Once these goals have been determined, we begin with an impacted goal and ask “Why” questions to add detail to the analysis.  The safety goal was impacted due to the death and injuries.  These occurred because of the explosion AND because people were in the proximity of the explosion.  Had the explosion occurred after a complete evacuation, the injuries would have been substantially reduced, if not completely prevented, although the property goals would have still been impacted.

An evacuation ws not ordered by the fire department, who deferred to the utility company.  The utility company was slow in determining that an evacuation was needed.  There was general confusion about the responsibility for determining an evacuation.   Per the city’s emergency response plan, the Incident Commander is responsible for evacuations.  However, no Incident Commander  was named on-scene until after the explosion, as it was determined that no incident yet existed.  Because quite a bit of flexibility is generally needed in determining whether an evacuation is needed (as an evacuation itself can be dangerous), the emergency response plan is necessary somewhat confusing (in this case, contained in a 90-page document).

The explosion itself resulted from an unknown heat source within the restaurant igniting leaked natural gas.  The natural gas was leaking as a result of being struck by a boring machine being used to install fiber-optic cable in the area.  It was later determined that the contractor did not have the necessary permit for the work, though it’s not clear if that led to confusion on the location of the gas lines, or if they were mislabeled, or if it’s just that it’s really difficult to see lines when digging deep trenches using a boring machine.

The extent and probability of an explosion is related to the volume of gas released during a leak.  Had the gas been turned off earlier, the explosion might have been avoided, or lessened, reducing the impacts to all the goals.  The gas was not turned off before the explosion, and after the explosion continuing fires made the shut-off locations difficult to reach.  it’s not clear why the gas wasn’t turned off immediately, though the choice to do so  does result in other impacts, such as the loss of gas to other customers.  In cases where the true extent of the issue is not known, it is difficult to make these decisions and limit potential effects.

Because one of the issues was not knowing the extent of the leak, it has been suggested that all fire department trucks be equipped with natural gas sniffers.    Additionally, an update to the city’s evacuation protocol has been called for that would, among other changes, give authority to the first arriving public safety official  to order an evacuation, resulting some of the confusion that led to the tragedy in Kansas City.

As this example shows, it’s not only attempting to prevent these events that’s important but also ensuring that emergency plans and protocol clearly define actions to be taken as well as responsible parties.  Drills and simulations can ensure that the plans and protocols are even more effective.   This is true not only for cities and fire departments but for any organization tasked with the safety of people . . . which is to say, all of them.

To view the Outline, Timeline, Cause Map, and Solutions, please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Brazilian Nightclub Fire Kills At Least 238 People

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By ThinkReliability Staff

A pyrotechnics display meant for outdoor use turned deadly at a band concert in a nightclub in Brazil on January 27, 2013.  The pyrotechnics – which were set off by the band – lit the soundproofing on the ceiling and it spread – with little help from non-functioning fire extinguishers.  The large crowd had difficulty leaving the club, which had only one exit blocked by bouncers who thought patrons were trying to leave without paying.

This tragic incident can be examined using a Cause Map, or visual root cause analysis, which visually diagrams all the causes and impacts related to the nightclub fire.  We begin with the impacted goals.  The safety goal was impacted due to the at least 238 people who were killed and 100 who were injured.  The severe fire is an impact to the environment.  People were unable to exit, which can be considered an impact to the customer service goal.  The loss of the use of the nightclub is an impact to the production goal, and the damage is an impact to the property goal.  Additionally, members of the band and owners of the nightclub are being held, potentially to be charged with manslaughter.  This can be considered an impact to the employee goal.

We begin developing cause-and-effect relationships by asking “Why” questions.  People were killed because they were in the nightclub, unable to exit and there was a severe fire.  Questions have been raised about why the nightclub was even in operation, as its licenses were expired.  People were unable to exit because there was only one exit – completely insufficient for a facility of this size and no windows in the bathroom.  Bouncers were blocking the only exit because they believed patrons were trying to leave without paying – nobody had told them of the fire.  Difficulty seeing the exits due to smoke and lost power resulting from the fire complicated matters even more.

The fire began when the pyrotechnics (heat) lit the soundproofing on the ceiling (fuel).  The fire was unable to be put out due to difficulties reaching the ceiling and non-functioning fire extinguishers.  Specific solutions are being debated by lawmakers in Brazil, but it is hoped that this tragedy will draw attention to – and improve – some of the conditions that contributed to this tragedy.

To view the Outline and Cause Map, please click “Download PDF” above.  Click here to read about another building fire.