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

Impure Injections Used

By Kim Smiley

Research is been suspended at a prominent brain-imaging center associated with Columbia University.  Food and Drug Administration investigations found that the Kreitchman PET (positron emission tomography) Center has injected mental patients with drugs that contained potentially harmful impurities repeatedly over the past four years.

Investigations by the lab determined that no patients were harmed from the impurities, but this is still a significant issue in a nationally renown laboratory.

How did this happen?

This issue can be investigated by building a root cause analysis as a Cause Map.  To start a Cause Map, the impact to the organization goals is determined.  In this example, this issue is obviously an impact to safety because there was potential to harm patients.  It is also an impact to the production-schedule goal because research has been suspended.  Additionally, this problem is an impact to the customer service goal because this issue raises questions about the validity of research results.

To build a Cause Map, select one goal and start asking “why” questions to add causes.  In this case, the first goal considered will be the safety goal.  There was a potential for injury.  Why?  Because impure injections were given to patients.  Why?  Because the injections are necessary for research, because the labs typically prepare the compounds themselves and because the lab prepared the compounds incorrectly.  When there is more than one causes that contributed, the causes are added vertically with an “and” between them.

Each impacted goal needs to eventually connect to the same Cause Map.  If they do not, the impacted goal may not be caused by the same problem and the goals should be revisited.

To continue building the Cause Map, keep asking “why” questions for each added cause until the level of detail is sufficient.

A Cause Map can be as high level or as detailed as needed.  The more significant the impact to the goals, the more likely a detailed Cause Map will be warranted.  Once the Cause Map is completed, it can be used to develop solutions to help prevent the problem from reoccurring.

In this example, the lab is currently changing management and reorganizing procedures to help prevent the similar problems in the future.

To view an initial Cause Map for this issue, please click the “Download PDF” button above.

Root Cause Analysis - Incident Investigation

Mine Explosion in Colombia

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.

Root Cause Analysis - Incident Investigation

Multiple Beauty Salon Car Crashes

by Kim Smiley

On May 25, 2010, the National Highway Traffic Safety Administration (NHTSA) released new data about Toyota’s unintended acceleration issues, increasing the number of deaths potentially linked to the issue to 89.  Additionally, the NHTSA stated that nearly 6,200 complaints regarding acceleration issues in Toyotas have been received since 2000.

The acceleration issues have already resulted in massive recalls of Toyota vehicles in the US.  Nearly 5.4 million vehicles were recalled to fix issues with floor mats that could potentially shift out of position and an addition 2.3 million vehicles were recalled to repair sticking accelerator pedals.  No additional causes have been found for the acceleration issues at this time, but there are a wide range of theories that include electronic issues and solar flares.  Toyota denies that there are any additional causes of the acceleration at this time.

The US government is continuing to investigate the claims of unintended acceleration in Toyotas and an independent 15-month study by the National Academy of Sciences will begin in July.

A recent Wall Street Journal article discussed one of the stranger trends that have been found in the Toyota car crash data.  There have been an unusual number of accidents at beauty salons.

Why beauty salons?

Just like any problem, this issue can be investigated using a root cause analysis built as a Cause Map.  In this case, the Safety goal would be impacted because there is a potential for injury for both the driver and people inside the salon.  Additional causes can be added to the Cause Map by, asking “why” questions and adding boxes to the right.

In this example, the article speculates that the some of the potential causes may be the age of the drivers involved (older women tend to visit salons more frequently), location of the salons (many are in strip malls near parking lots) or the architecture of salons (many have large glass windows that might distract drivers).  No formal investigation has been done to determine the actual causes of this strange trend, but it is interesting to lay out the potential causes and see what factors might be contributing to the hair salon car crashes.

Click on the “Download PDF” button above to view the initial Cause Map.

Root Cause Analysis - Incident Investigation

Known Terror Suspect Boards Plane

By Kim Smiley

On May 1, 2010 authorities found a car bomb in a smoking Nissan Pathfinder in Times Square in New York City (NYC). The bomb had been ignited, but thankfully failed to explode and was disarmed before any damage was done.

The vehicle identification number (VIN) number had been removed from the dashboard and the door sticker, but police retrieved it from the bottom of the engine block.  The VIN was used to identify Faisal Shahzad as the person who recently purchased the car.  The investigation used this evidence in addition to other information to identify Mr. Shahzad as a suspect in the car bomb attempt.  Early in the afternoon of May 3, his name was added to the no-fly list and an email notification was sent to airlines.  In order to view the new name, airlines would have needed to check a website for the most recent no-fly list.

As the investigation continued, Shahzad was put under surveillance, but somehow eluded authorities and drove to JFK airport in NYC undetected.  The evening of May 3, he bought an airline ticket and was able to get through security and board a plane traveling to United Arab Emirates.  He boarded the plane approximately seven hours after his name was added to the no-fly list.

Luckily, investigators learned that Shahzad was on the plane when a final passenger list was sent to officials at the federal Customs and Border Protection agency minutes before takeoff.  He was apprehended before the plane took off and is now in custody.

How was a suspect on the no-fly list allowed to board a plane headed overseas?

A root cause analysis built as a Cause Map can be used to analyze this incident.  This incident is an impact to the Safety goal because a known terror suspect on the no-fly list nearly left the country.  The Cause Map can be built by starting at the impacted goal and asking why questions to add causes.  In this example, the suspect nearly got away because he was allowed to buy a ticket and got through security.  This happened because the airline was using an outdated version of the no-fly list that didn’t include the name because it had recently been added to the list.

There are still a number of causes that are unknown in this case, but an initial Cause map can be viewed by clicking on the “Download PDF” button above.

Root Cause Analysis - Incident Investigation

NASA Balloon and Telescope Payload Crash

By Kim Smiley

The plan for the telescope was exciting.  It was a nuclear compton telescope (NCT), built to map gamma rays, to aid in locating astrophysical objects like supernovae, pulsars and black holes.  The telescope was being launched by balloon from  Alice Springs, Australia for an optimal view.  The NCT team had been hard at work and on April 29, 2010, eagerly awaited the launch, as did news crews and other onlookers.

However, instead of delivering the telescope to nearly 25 miles above ground, the gondola carrying the telescope left the launcher awkwardly and dragged across the ground.  It hit and overturned a nearby vehicle and barely missed injuring the spectators gathered nearby.  The telescope suffered major damage.  The build team was devastated and will likely be spending considering effort and resources rebuilding or repairing it.  As a result, all balloon launches were put on hold.  (The next launch was scheduled for this month.)

Although an in-depth investigation is taking place, we can begin a root cause analysis with the information that is known so far.  The near miss of injuring onlookers is an impact to the safety goal.  The devastation of the build team is an impact to the customer service goal.  Balloon flights on hold are an impact to the production goal.  The damage to the telescope and the vehicle are impacts to the property goal.  The rebuild or repair of the telescope is an impact to the labor goal.  With these impacted goals in mind, we can begin a Cause Map.

The damage to the telescope occurred when the telescope was dragged across the ground.  It was dragged across the ground because the balloon did not get airborne, the gondola launched improperly (as best as we can tell from the video), and the gondola was carrying the telescope.  It’s likely that the high winds in the area impacted the ability of the balloon to get airborne.  It’s unclear why the gondola was improperly launched – more information on this should come out through the investigation.  The gondola was carrying the telescope so that it could be launched by balloon to complete its mission.  A reason given for using a balloon is that it is less expensive to build and launch than an orbiter.

As more information is released regarding this incident, we can add it to our Cause Map.  As NASA releases more details about what will be done to prevent future incidents of this kind, we can include these solutions

Root Cause Analysis - Incident Investigation

The Future of NASA

By Kim Smiley

A previous blog discussed a shortfall in the National Aeronautics and Space Agency (NASA) budget.  The lack of funding put NASA’s organization goals in jeopardy, including a planned return mission to the moon.  Then-President George W. Bush had tasked NASA to return to the moon five years ago and NASA has been working toward this goal since.

President Obama announced his vision for NASA during a speech Kennedy Space Center on April 15.  He canceled plans for a moon mission and redirected NASA to focus on sending astronauts to an asteroid and work toward an eventual Mars landing.  The proposed budget would boost NASA funding by six billion over the next five years.

President Obama’s plan calls for private companies to fly to the space station using their own rockets and ships, freeing up NASA resources for basic research and development of technologies for trips beyond earth’s orbit.  The final space shuttle mission is scheduled for September 2011 after which the US will depend entirely on Russia to carry astronauts to the space station until a replacement for the space shuttle is developed.  Additionally, the space station’s life would be extended by five years as part of the Obama plan.

The planning necessary to achieve a goal of this complexity is mind boggling.   There are many new technical issues to consider and brand new equipment will need to be designed.  There are many, many potential problems that could arise during this design process and mission.

Cause Mapping is often used to perform a root cause analysis of an incident that has occurred, but it can also be used to proactively approach a problem by building a map that captures failures that could happen.  Identifying potential problems before they happen would allow NASA to mitigate risks and allocate resources efficiently.

Cause Maps could be built to any level of detail that was deemed appropriate.  Cause Maps could be developed to capture all potential failure modes for something as small as a single component or for something as large the entire mission.

Root Cause Analysis - Incident Investigation

Deadly Mine Explosion in West Virginia

By Kim Smiley

Around 3 pm on April 5, 2010 in Montcoal, West Virginia, a huge explosion rocked the Upper Big Branch South mine owned by Massey Energy Company.  At least 25 miners were killed, both from the explosion itself and suffocation caused by high levels of dangerous gases.

There are still 4 miners missing.  The missing miners were working farther back in the mine and the hope is that they were able to reach one of the airtight chambers stocked with enough food, water and oxygen for several days.  Rescue efforts are underway and drilling efforts are ongoing to add additional ventilation so that the gas levels can be reduced to safe levels to allow rescue workers to enter the mine.

This is the worst mine accident in the US in over 20 years. If the 4 missing miners are not found alive, this accident will have the highest number of fatalities since a 1970 mine killed 38 in Hyden, Kentucky.

What triggered this explosion is not known at this time, but both state and federal agencies have initiated investigations.

Even though many details are still unknown, a root cause analysis can be started by building an initial Cause Map.  There was an explosion which means there must have been an ignition source, flammable material and oxygen present.

The source of the flammable material is known since there were high methane gas levels in the mine.  Methane gas is naturally occurring in coal mines and must be continually vented.  It can also be assumed that the mine ventilation was inadequate for some reason since the gas levels built up.  Coal dust accumulation may have also contributed to the accident since powdered combustible material in an enclosed space is a very explosive combination.

The source of the spark that ignited the explosion is still unknown.

More information will become available as the investigation proceeds and a more detailed Cause Map can be built as additional causes are added.

Media reports about the accident have discussed past safety violations cited at the mine, but it won’t be clear if the accident was preventable until the investigation is completed.  What is known that in March 2010, the Mine Safety and Health Administration cited the Upper Big Branch mine for 53 safety violations.  In additional to the recent citations, there was also a troubling increasing trend in citations, which more than doubled between 2008 and 2009.

Hopefully, the information obtained during the investigation will provide useful lessons learned that can be implemented to prevent a similar accident in the future.

Root Cause Analysis - Incident Investigation

Contaminated Drinking Water

By Kim Smiley

In 1922 the United Nations designated March 22 as World Water Day.  In honor of the occasion, a report titled “Sick Water” was published this week detailing issues with water pollution throughout the globe.

According to the report, two billion tons of pollution consisting of human and animal waste and industrial chemicals are dumped into waterways every day.  Almost 80 percent of sewage around the globe goes into waterways untreated.

Millions of people lack basic infrastructure including access to clean water, sanitation systems and water treatment facilities. The massive water pollution that results from this situation kills nearly 1.5 million children under age 5 every year.  Over half of the hospital beds in the world are occupied by people with illnesses caused by drinking contaminated water.

Even in developed nations, water pollution is a problem because many chemicals aren’t removed by the water treatments that kill the pathogens from sewage.  Chemicals from antidepressants, birth control, illegal drugs, sunscreen, and insect repellent are just some of the pollutants that have been found in US drinking supplies.

In addition to human illnesses caused by dirty water, water pollution has a large scale impact on the environment.  Over two billion tons of water is polluted daily, resulting in death of fish and choked coral reefs.

While the problem of water pollution isn’t a problem that is traditionally approached by root cause analysis, a Cause Map can be built to examine the causes of a wide range of issues.  Click on the “Download PDF” button to view a high level Cause Map of this issue.  The Cause Map could be expanded to incorporate as many causes as desired.

Root Cause Analysis - Incident Investigation

Salmonella Recall

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By Kim Smiley

A number of food products have been recalled recently because of potential salmonella contamination.  The recall list is still growing and has the potential to affect thousands of items in nearly every aisle at the grocery store.

The contamination originated in hydrolyzed vegetable protein (HPV) which is a common, inexpensive salty and savory flavor enhancer used in a variety of products.  All HPV from Basic Food Flavors of Las Vegas made since September 17, 2009 has been recalled.   For a list of all recalled items and more information, please visit the Food and Drug Administration webpage.

The salmonella contamination occurred in the processing equipment at a one location, but HPV from that supplier was sold to food manufacturers nationwide.  HPV is a specialized product and there are only a few suppliers for it so issues at a single supplier have the potential to affect a significant percentage of the processed food supply.

The contamination was identified when a consumer of the Basic Food Flavors identified salmonella in a batch of HPV they had purchased and reported it to the FDA, utilizing the new FDA Reportable Food Registry.  The FDA then inspected Basic Food Flavors and found salmonella in the plant’s processing equipment.

The overall risk to the public is considered low.  No cases of illness from this contamination have been reported.  As long as products are heated to a sufficient temperature, either during the manufacturing process or cooked after purchase, the salmonella risk will be eliminated.  The highest risk products are ready to eat products such as chips, dips, and dip powder.

The investigation of this incident is still ongoing, but a basic root cause analysis can be started.  The safety goal is obviously impacted since salmonella can potentially cause illness and even death in the case of weakened immune systems.  In this case, the customer service goal would be impacted as well because the recall may affect customer confidence and sales of the recalled items.

Click on the “Download PDF” button to view an initial Cause Map of the salmonella contamination.  The Cause Map can be expanded as more details are available.

Root Cause Analysis - Incident Investigation

Death of Luger at 2010 Winter Olympics

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By Kim Smiley

On February 12, 2010, Nodar Kumaritashvili, an Olympic luger from the country of Georgia, was killed during a practice run.  He lost control of his sled, flew off the track and hit a steel pole.

The investigation into the accident is still ongoing, but a root cause analysis can be started with the information that is available.  This accident obviously impacts the safety goal because an athletic was killed and it also had potential to impact the schedule goal because the track was closed during the initial investigation.

There are a number of causes that can be added to the Cause Map.  One of the more obvious causes for the accident is that the athletic was traveling at high speeds.  This occurred because the crash happened near the bottom of the track so the sled was near its top speed.  Additionally, the Vancouver Olympic track is also a particularly fast track.  Top speeds on the track were predicted to be 96 mph, nearly 6 miles faster than the standing 2000 world speed record.

How did the track get designed to be so much faster than typical tracks?  There are a number of causes that contributed to fast design.  The designers choose Whistler as the site of the track because Whistler has a colder climate than the alternatives, resulting in firm, fast ice and because there is high tourist traffic there that would help make the track a commercial success after the Olympics.  Whistler was also the site of the Olympic alpine events.

The land that was available at Whistler was long and narrow.  The site was a valley approximately 100 yards by 800 yards.  By comparison, the Calgary track was about 300 yards wide and Salt Lake City’s track was 500 yards.  Designing a track to fit in the available region meant the track couldn’t include any long curves that slow down speed as is typical.

The result was the fastest track in the history of the sport.

As the investigation continues, more details become available and they can be added to the Cause Map.

In order to ensure safety during the Olympic Games, several solutions were implemented following the accident. A wooden wall was added to the curve where the accident occurred to keep athletics on the track, the steel poles were padded and events were started lower on the track to limit the maximum speed.  The lower start was predicted to slow top speeds in the men’s events by about 5 mph.

There have been several crashes on the course since the accident, but thankfully no farther significant injuries have occurred.