All posts by Kim Smiley

Mechanical engineer, consultant and blogger for ThinkReliability, obsessive reader and big believer in lifelong learning
Root Cause Analysis - Incident Investigation

Cruise Ship Loses Power

By Kim Smiley

Part of the excitement involved in passenger cruises is access to remote areas of the world.  However, when a ship runs in to trouble, that remoteness can result in extremely difficult conditions.  This was the case on the Costa Allegra, which suffered an engine room fire in the Indian Ocean.

Passengers aboard the Costa Allegra experienced sub-standard conditions when the ship lost power and propulsion due to an engine room fire.  During the three days while the ship was being towed to land, there was no air conditioning, lighting, or running water.  Food and drinking water were provided by helicopter.

We can examine the causes and effects of this issue in a Cause Map, or visual root cause analysis.  With the Cause Mapping process, we begin by examining the impact to the goals.  Namely, when the incident occurred, which of the organization’s goals were not met?  In this case, although there appeared to be no injuries resulting from the fire itself (although some passengers may have become ill during the resulting conditions) there was the potential for severe injury resulting from the fire and then the lack of power that resulted.   Additionally, the customer service goal was impacted by the lack of running water, air conditioning, and lighting.  The schedule goal was impacted because the ship needed to be towed for 3 days.  The property goal was impacted due to the damage to the ship from the fire, and the labor goal was impacted due to the need for the ship’s crew to stand guard against pirate attack.

Once we’ve determined the goals that were impacted, we can use them as a basis for our map, and ask “Why” questions to add more detail.   Here, an engine room fire on the ship resulted in the loss of ship power, causing the loss of air conditioning, lighting and running water, and the loss of ability for the ship to propel itself, necessitating a tow.  The length of the tow is also affected by the type of ship doing the towing.  In this case, the first ship to arrive to the aid of the Costa Allegra was a fishing vessel.   Although tugboats later arrived, the Costa Allegra requested that the fishing vessel continue the tow, although it is believed that the tugboats would have been able to speed up the tow, possibly resulting in the ship arriving as much as 12 hours earlier.  The cruise ship company has stated that the tow was not changed in consideration of the consistency of the voyage for the passengers but there are also potentially financial considerations.  Assistance to people at sea is not paid, but assistance to ships is.  Thus, the fishing vessel actually entered into a contract with the cruise ship for the tow.

Part of the reason that a fishing vessel was the first to arrive is that there is little maritime traffic in the area.  This is due to the remoteness of the area in which the cruise ship was traveling, as well as the risk of piracy.  This, of course, led to a constant armed guard on the disabled ship to protect from potential pirate attack.

The location to which the ship was towed also impacts the length of the tow.  It was determined that smaller ports closer to the location of the disabled Costa Allegra could not accommodate the large number of passengers on the ship, so the ship was towed to an island of Seychelles.

The cause of the fire itself is still under investigation, although it is believed that an electrical fault is a likely cause and that arson is not likely.  As more information becomes available, we can add that information to the Cause Map as well.

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

Root Cause Analysis - Incident Investigation

Collapse of Gulf of Maine Cod Population Feared

By Kim Smiley

Recent estimates of the Gulf of Maine cod population show that cod is being over fished to the point that the population is at risk of collapse, meaning the numbers become so low the population cannot recover.  Federal regulators are trying to determine the best course of action to protect the fish population which may include severely restricting cod fishing in the Gulf of Maine.

The declining cod population problem can be analyzed by building a Cause Map, an intuitive, visual root cause analysis.  The first step in building a Cause Map is to determine what goals are impacted by the issue.  In this case, the environmental goal is impacted because the cod population may collapse, but the economic impacts of this issue are also a major concern.

Cod has long been a major source of income for New England fishermen, bringing in $15.8 million in 2010.  Restricting cod fishing would also impact the ability to catch other fish because cod is often also bought up in nets when other fish are targeted.  Cod are bottom swimmers along with other popular fish such as flounder and haddock and it’s impossible to catch one type of fish without catching the others.

The cod population is declining because the fish are not reproducing fast enough to keep up with fishing. Fishing of cod occurs for several reasons.    First, cod is caught and sold because it is profitable.  Cod meat is high in protein, low in fat and easily filleted. Additionally, federal regulations allows fisherman to catch a set quota of cod.  One of the potential causes of the declining cod population may be that these quotas are set too high to for the cod population to continue to grow.

The federal limits on cod fishing over the past few years were set based on information from 2008 that showed a significantly higher cod population than the estimates determined by the recent population assessment.  It’s not clear why the numbers of cod varied so dramatically between the current estimates and the ones from 2008, but the dramatic swing in fish population estimates has been a source of many complaints by fishermen.  It may also be worth considering whether any environmental factors have impacted the fish population.  Cod population can be affect by many factors besides fishing, such as varying ocean temperatures or changes in their food supply.

After considering severe cuts of up to 82 percent, federal regulators appear to be willing to reduce the amount of cod allowed to be caught by only 22 percent for the 2012 fishing season.  This is only a one year agreement and fishermen will likely face severe cuts on cod fishing limits again in 2013.   At this time it’s not clear whether there is a way to save the historic fishing industry in the Gulf of Maine and ensure a healthy population of cod in the region.

To view a high level Cause Map of this issue, click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Several Incidents at CA Nuclear Plant Raise Concerns

By Kim Smiley

Within a week, three separate incidents occurred at the San Onofre Nuclear Generating Station, located near heavily populated areas, raising new concerns about the safety of the nuclear power plant.

This issue can be investigated by building a Cause Map, an intuitive, visual root cause analysis.  The first step in building a Cause Map is to determine what goals are impacted by the issue being considered.  In this case, the main goal being considered is safety.  If the Cause Map was being built from the perspective of the power plant company, then the production and schedule impacts would also need to be considered, but in this example we will focus on the safety impacts.

The safety goal is impacted because some people are concerned about the safety of the power plant because it is near heavily populated areas and three separate incidents occurred within days of each other.  The three incidents in question were the release of a small amount of radiation, discovery of unexpected amounts of wear on steam generator tubes, and the potential contamination of a worker.

A small amount of radiation was released because a steam generator tube, which carries radioactive water, was leaking.  Luckily, the leak was small and the plant was quickly shut down after the leak was discovered so no significant amounts of radiation were released.  A second reactor unit is currently shut down for maintenance and inspection of the steam generator tubes found significantly more wear than expected on some of the tubes.  The wear was unexpected because the tubes have only been in service for 22 months and two tubes had 30% wall thinning, 69 tubes had 20% wall thinning and 800 had 10% wall thinning.  The situation is being investigated, but neither the cause of the wear nor the best course of action has not yet been determined.  The final incident was the potential contamination of a worker because he fell into a reactor pool.  According to media reports, the worker was trying to retrieve a flash light and lost his footing.

To view a high level Cause Map of this incident, click “Download PDF” above.  The Cause Map can be expanded as more information comes available so that it can document and illustrate as much detail as needed to evaluate the issues.

As it stands, both the reactor units with the steam generator tubes are shut down.  The unit that experienced the leak is shutdown pending investigation and any necessary repairs.  The second unit that had the unexpected wall thinning in the steam generator tubes is in a planned shutdown of several months while it is refueled and upgraded.  The plants will be brought back online once it’s determined safe to do so.

Root Cause Analysis - Incident Investigation

Number of Poached Rhinos Hits All Time High

By Kim Smiley

Rhinoceros, commonly called rhinos, have long been hunted for their horns.  Three of the five species of rhinos are considered critically endangered.  According to the National Geographic News Watch, at least 443 rhinos were killed in South Africa in 2011, a significant increase from 333 the previous year.  South Africa is home to more than 20,000 rhinos, which is over 90% of the rhinos in Africa.  For a little perspective on how significantly the problem has grown, South Africa only lost about 15 rhinos a year a decade ago.

Experts in the field have concluded that the number of rhinos lost through unnatural means, both illegal poaching and the less common legal hunts allowed by the government, will result in a decline in the population of rhinos.

This problem can be investigated by building a Cause Map, an intuitive, visual root cause analysis method.  To begin a Cause Map, the impact to the organizational goals is first determined and then “why” questions are asked to add Causes to the map.  In this example, the major organizational goal being considered is the impact to the environmental.  The environmental goal is impacted because the poaching of rhinos hit an all time high.  This happened because of two things, poachers want to hunt rhinos and the methods in place to prevent poaching are ineffective.

Poachers want to hunt rhinos because the black market value of their horns is extremely high.  They are worth more than gold by weight.  Poachers are able to sell the horns for high prices because consumers are both willing and able to pay huge sums.  There is a strong market for rhino horn because of long standing beliefs that rhino horn has medicinal uses, primarily in Asian cultures.  The number of people able to come up with large amounts of money has also increased with the rise of an affluent middle class in many Asian countries.

The poaching is also increasing because it’s very difficult to prevent it.  The rhinos live in a large, wild habitat.  It’s simply difficult and expensive to patrol and defend such a large region.  The poachers are very well armed because they are backed by international crime syndicates with deep pockets.  It’s a huge challenge for the governments involved to prevent the poaching from occurring.

This problem will likely continue to increase until the demand for the rhino horns starts to decrease.  Modern medical research has concluded that rhino horn has no medicinal value, but as long as people are willing to pay big money for them, someone will find a way to meet that demand.

As an interesting aside, theft of rhino horns from museums has also risen dramatically.  At least 30 horns were stolen from museums this past year.  Click here to learn more.

Root Cause Analysis - Incident Investigation

Driving While Distracted

By Kim Smiley

A recent study by the National Highway Traffic Safety Administration determined that 3,092 people died last year in car accidents that involved distracted driving.  This means that texting and talking on cell phones contributed to one out of every 11 traffic deaths in the US last year.

It’s difficult to compare this number to the findings from previous years because the definition for distracted driving was refined.  The number for 2011 included only the effects of texting and using a cell phone while driving while other non-technological distractions were included previously.

One thing that is clear, the popularity of texting is rapidly increasing.   196 billion text messages were sent in June 2011,  a nearly 50% increase from June 2009.

A Cause Map can be built to investigate this issue.  A Cause Map is a visual, intuitive form of root cause analysis.  To view a high level Cause Map of this example, click on “Download PDF” above.

One of the causes that contributed to this problem is that people aren’t pulling over when they need to use their cell phones while driving.  There are a number of reasons for this.  The first being, that pulling over is rarely convenient.  Second, people don’t see the need to pull over.  And third, whatever laws might be in place prohibiting distracted driving aren’t effective.

It isn’t clear why people don’t believe they need to pull over.  The study by the National Highway Traffic Safety Administration found that many people don’t think that cell phone usage and texting negatively affect their driving skills.  Many studies have determined that just isn’t the case.  Using a cell phone, either to talk or to text while driving will slow down a driver’s reaction time.   A study by the US Department of Transportation found that sending or receiving a text takes a driver’s eyes off the road for an average of 4.6 seconds.  At 55 mph, a car will travel the length of a football field in that time.

Following these findings, the National Transportation Safety Board (NTSB)  has recommended a nation wide ban on the use of all portable electronic devices, including cell phones.  This would include using a hands-free device to operate a cell phone. The only exceptions to the ban would be use of GPS systems and cell phone use in case of emergency.  Only time will tell what effect the NTSB recommendation has future laws.

Root Cause Analysis - Incident Investigation

Roofing Asphalt Spilled on PA Turnpike

By Kim Smiley

On November 22, 2011, a tanker truck spilled a large quantity of roofing asphalt along nearly 40 miles of the Pennsylvania Turnpike.  The spill damaged many vehicles and caused a traffic nightmare as crews worked for hours to clean the mess up.  The timing of this incident was also unfortunate because it occurred on the evening before Thanksgiving, traditionally a very high traffic time.

This incident can be analyzed by building a Cause Map, which is an intuitive, visual method for performing a root cause analysis.  The first step when building a Cause Map is to determine how the incident impacted the goals of the organization.  In this example, the safety goal was impacted because there was potential for car accidents and injuries.  Thankfully, no one was actually hurt, but it is important to note the potential impact in order to fully understand the ramifications from an event.  Additionally, the traffic delays are an impact to the schedule goal.  The customer service goal was also impacted because over 150 cars were damaged by the spill.

Now the Cause Map is expanded by asking “why” questions and adding Causes that contributed to the incident in order to show the cause and effect relationships.  In this example, there was a potential for injuries because more than 150 cars were damaged while driving.  The cars were damaged because they drove onto a spill of wet roofing asphalt.  The asphalt covered the cars and their wheels with thick, sticky goo and many of them undrivable.  The cars drove over the roofing asphalt because a tanker truck had leaked onto the road over a long distance.

The tanker truck was carrying a large load of the roofing asphalt, between 4,000 and 5,000 gallons, so there was a large quantity that could potentially be spilled.  Initial findings indicate that the tanker truck spilled the asphalt because of a leaking valve.  Details on why the valve leaked aren’t yet available, but they can be added to the Cause Map as they are known.

Another Cause of this incident is the fact that the driver of the truck was unaware that his truck was leaking so he drove almost 40 miles before he stopped and realized that there was a problem.    It was evening when the leak occurred so the driver wasn’t able to see evidence of a leak easily.

Media reports have stated that the driver of the tanker truck will be charged in the incident.  He is facing charges of failing to secure his load and failing to obey a trooper.  The website of the trucking company has posted a statement encouraging affected vehicle owners to file claims though their insurance.

Click on “Download PDF” above to view a high level Cause Map of this incident.

Root Cause Analysis - Incident Investigation

Pilot Locked in Bathroom Nearly Results in Terror Alert

By Kim Smiley

In order for a flight to take off and land safely, many complex mechanical systems have to work for the plane to function properly.  Additionally, pilots need to be properly trained and proficient at their jobs.  Airline processes also have to work in order to smoothly ticket, security screen and board all the passengers.

The number of things that have to work for a successful commercial airline flight is impressive.  A recent incident highlighted that even the smallest hiccup, a broken bathroom lock for example, has the potential to cause big issues in the complex world of commercial flights.

On November 18, 2011, a pilot accidentally got locked inside a bathroom just prior to landing at LaGuardia.  This incident almost resulted in an emergency being declared and terrorist alert being issued.  In order to understand this incident, a Cause Map can be built.  A Cause Map is a visual root cause analysis that illustrates the cause and effect relationship between all the Causes that contribute to an event.

In this example, the copilot considered declaring an emergency because the pilot was gone from the cockpit longer than excepted and an unknown man with an accent knocked on the cockpit door.  The copilot was concerned that this might be a potential hijacking attempt.  His concern was caused by the intended destination being NYC and the 9/11 attacks that occurred there 10 years ago.

The pilot was taking longer than normal because the bathroom door lock had jammed when he had tried to exit after a bathroom break.  The unknown man was a well-intended passenger who had heard the pilot calling for help.  The pilot had given him the password to access the cockpit because all other crew members were inside the cockpit.  There were two reasons that all other crew members were inside the cockpit.  First, regulations require that at least 2 crew members are inside the cockpit at all times.  Second this was a small airplane staffed with only 3 crew members.  If the pilot or copilot needed to use the restroom, the only flight attendant had to enter the cockpit to meet the rules.

Luckily, the pilot was eventually able to free himself from the bathroom and return to the cockpit before anything too exciting happened.  The plane landed as scheduled.  The FBI and Port Authority cops met the plane, but after briefly talking to the passenger involved it was quickly determined that nothing suspicious had occurred.

Root Cause Analysis - Incident Investigation

First Airline Fine for Tarmac Delay

by Kim Smiley

The Department of Transportation (DOT) recently issued the first fine for violating new rules that limit how long passengers can be kept onboard a plane waiting on the tarmac. The new regulations, commonly called the tarmac delay rule, state that passengers may not be kept onboard a plane waiting on the runway for more than 3 hours without being given the opportunity to deplane.  The rules also require that airlines provide adequate food and drinking water for passengers within 2 hours of a plane being delayed on the tarmac and to maintain operable lavatories.  The tarmac delay rule, which went in effect April 2010, was created following several incidents where passengers were kept onboard airplanes for long periods of time.

The incident that resulted in a fine is not the first violation of the 3 hour rule, but this is the first time the DOT has taken the step of issuing a fine.  The potential fees for violating the rules are substantial.  Airlines can be fined $27,500 per passenger when the tarmac delay is beyond 3 hours.  This quickly adds up, especially if multiple flights are involved.  In this example, 15 American Eagle flights were delayed beyond the 3 hour limit on May 29, 2011 at O’Hare International Airport in Chicago.   608 passengers were affected and American Airlines was fined a whopping $900,000.

What happened?  How were so many flights on the tarmac so long?

This example can be analyzed by building a Cause Map, a method for performing a visual root cause analysis.  A Cause Map is built by determining the cause-and-effect relationships between all the causes that contributed to an incident.  Click on “Download PDF” above to view a high level Cause Map of this incident.

As with many airline delays, inclement weather played a major role in this incident.  Flights had been delayed taking off from O’Hare and planes that were scheduled to have departed were still sitting at the gates.  Planes that landed had nowhere to go so they sat on the tarmac waiting for an open gate.

Passengers were not given an opportunity to deplane within 3 hours.  The airline has procedures to get passengers off the planes even if the planes themselves were stuck waiting on the tarmac, but the procedures were not implemented within the 3 hour time limit.  If there was no delay limit, an airline couldn’t violate it so the new creation of the tarmac delay role is also a cause to consider in this incident.

It will be interesting to see how this large, first of its kind fine affects the airline industry as a whole.   Statistics show that the new rules have successfully reduced long tarmac delays.  The first year that the rule was in effect, airlines reported only 20 tarmac delays of more than 3 hours, but in the 12 months prior to rule there were 693 delays of more than 3 hours.  But this improvement may come at a high cost.  Especially now that the DOT has shown that they are willing to issue fines, industry analysts are warning that a possible unintended consequence of the new tarmac will be more canceled flights.  The fines are so hefty that airlines may cancel entire flights rather than risk violating the tarmac delay rules, which would obviously have an impact on travelers.  Only time will tell how the new rules will affect airline travel.

Root Cause Analysis - Incident Investigation

Driver Death at Indy 300

By Kim Smiley

The racing world was filled with sadness with the death of Dan Wheldon during the Indy 300 race in Las Vegas on October 16, 2011.  However, many race-car drivers were not shocked at the occurrence of a 15-car pileup that resulted in Wheldon’s death.  Specifically, these drivers note that the track – which was designed for NASCAR vehicles which travel at much slower speeds – was designed with high banks that allowed cars to accelerate heavily, reaching speeds of up to 225 miles per hour.  This also contributed to the cars remaining very close together, leaving little time or space for drivers to maneuver.  Although the track was smaller in diameter than other tracks (1.5 mile oval compared to the Indy 500’s 2.5 mile oval), it allowed 4 cars to race side by side, as was happening at the time of the crash.

Drivers say that the design of the track, the speed of the cars, and the unusually high number of competitors (34, when a full field is generally 26-28 cars) contributed to the crash.  Also, the open wheel design of Indy cars means that the driver has less control when contacting other cars.  In fact, many drivers said they expected at least one spectacular crash to result, given the circumstances.  Although racecars do have special features that protect drivers in a crash, the cars used in the Indy races have open cockpits, providing less protection.  It also appears that the protective roll hoop was missing on Wheldon’s car, though more information on this has not been released.

Other drivers were also injured in the 15-car pileup, though their injuries were not critical and all others have been released from the hospital.  Wheldon was said to have suffered “unsurvivable head injuries”.   After Wheldon’s death, the race – which had a $5 million prize in hopes to boost ratings – was stopped.   This is the first fatality to occur in Indy racing since 2006.  It is hoped that new safety measures – which Wheldon had been involved with – will continue to make Indy racing safer.  However, there are some drivers that believe that regardless of the safety features in the cars, Indy racing should be done on street courses, not ovals.

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

Root Cause Analysis - Incident Investigation

Explosion at Nuclear Waste Site Kills One

By Kim Smiley

An explosion at a nuclear waste processing site in France killed one and injured four workers on September 12, 2011.  The investigation is still ongoing, but it is still possible to create a Cause Map, a visual root cause analysis, that contains all known information on the incident.  As more information becomes available, the Cause Map can easily be expanded to incorporate all relevant details.  One advantage of Cause Mapping is that it can be used to document all information at each step of the investigation process in an intuitive way, in a single location.

When the word “nuclear” is involved emotions and fears can run high, especially following the recent events at the Fukushima nuclear plant in Japan.  This incident is a good example where providing clear information can help calm the situation.  The explosion in France happened when a furnace used to burn nuclear waste failed.  The cause of the explosion itself isn’t known at this time, but there is some relevant background information available that helps explains the potential ramifications of the explosion.

The key to understanding the impact of this incident is the type of nuclear waste that was being burned.  According to statements by the French government, the furnace involved was only used to burn waste with very low level contamination.  It burned things such as gloves and overalls as well as metal waste like tools and pumps.  No objects that were part of a reactor were treated in the furnace.  There are also no reactors at the site that could be potentially damaged by explosion.

There was no radiation leakage detected and the potential for large amounts of released radiation wasn’t there based on the type of material being processed.  It was a horrible accident that resulted in a death and severe injuries, but there was no risk to public health.

How France views nuclear power is also a bit of background worth knowing.  France is the world’s most nuclear power dependent country.  Fifty-eight reactors generate nearly three fourths of France’s power.  France is also a major exporter of nuclear technology.  The public relations issues associated with a nuclear disaster in France would be very complicated.

Once the investigation into this incident is complete, solutions can complete be determined and implemented to help prevent any future occurrences.