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A Lesson in Miscommunication: Valentine’s Day Blues

By Renata Martinez with contributions from the staff of ThinkReliability

I better preface this blog with a few comments….

It’s  not your average blog.  As a facilitator, I deal with a lot of serious problems on a daily basis.  Believe it or not I get these incidents stuck in my head and spend a lot of time thinking how I can better explain some lessons I’ve learned as a facilitator.  The goal of this blog is to offer a little perspective into an incident where “miscommunication” is identified and I wanted to use something you could probably relate to. Have you ever been in an argument with a significant other?  Maybe you didn’t see eye-to-eye on something (a Netflix option perhaps), or someone did something unexpected, or someone said something they didn’t mean (“Feel free to go golfing today; you don’t need to start on that to-do list”).

I also want to preface this blog by stating I am not a relationship counselor and I do not have a perfect relationship because of Cause Mapping.  However, I will say that Cause Mapping has helped me gain an understanding of a whole new perspective – his.

Without further ado, let me set the stage.  I have to take you back a bit.  Let me take you back to my Sophomore year in college. *enters dream state*

Valentine’s Day:  I hate it.  I’ve always thought it was a commercialized endorsement to express love.   The seemingly endless aisles in store after store of red and white hearts, chocolates, cards, teddy bears – gross.  …and then I met my future husband.  I was so head over heels for this guy, you would have thought I was 12 (but I was 20).  So when Valentine’s Day came around our new love I was actually excited.  The thought crept into my mind that I could be wow-ed this time; this could be it, I could learn to love Valentine’s Day.  I had the opportunity to relive every Nicolas Sparks novel ever written.  Expectations were set.

Leading up to the 14th, there was a conversation that took place that would ensure I will always despise the day…. I was asked what I wanted.  My mind quickly played one romantic scene after another but that’s not what came out of my mouth.  Instead I replied, “nothing.”  Well, being the literal person he is, he took this and ran with it – he got me nothing.  I was so disappointed because when I said “nothing”, OF COURSE I DIDN’T MEAN IT.   “Nothing” was a clear translation for: you figure it out, you surprise me with some immaculate plan. I didn’t want to spell out what I wanted; I wanted to be the cool, low maintenance, laid back girlfriend. I don’t think he was too impressed with my “cool, laid back attitude” when I came to the realization that I didn’t get anything for Valentine’s day – the first time I actually wanted something.

So that’s one branch of the Cause Map: why did I not ask for anything on Valentine’s Day?

At this same point of the Cause Map, it splits with an AND statement.  He also had to assume that I meant “nothing” when he asked.  In my mind it’s so obvious…it’s like when I haven’t talked or looked at you all day and when you ask “What’s wrong?” and I say “Nothing.”  I don’t mean it; it’s just an impulse reaction (and admittedly makes understanding me very difficult).  But since this was his first experience with me and this kind of situation, he didn’t think more about it.  He didn’t realize that I may actually want something.

I know this is a basic example of understanding both perspectives but it comes up a lot on investigations.  Understanding how people both give and interpret instructions/ directions is very important with regards to understanding solutions.  For instance, I will never say that I want “nothing” for a holiday ever again.  My new minimum “requirement” is a card. I really like cards.  And since I’ve got your attention, I’ll give you a little hint about present-giving: the presents should always be wrapped…in gift wrap (the bag from the store does not count).

Looking at solutions for him: he no longer takes the answer “nothing” literally.  Based on this experience, he now understands that I may not mean it.  So, the solutions identified will help him, but if we were looking at a different employee (or boyfriend in this example) – how do we ensure it doesn’t happen to them? This is where we need to consider others who may learn from this (not just those directly affected in this incident).  And this is why sharing lessons learned is so important.

By identifying both perspectives on the Cause Map, we can learn a lot about why an incident occurred (and what had to happen).  This yields more effective solutions that will prevent reoccurrence.  …after all: happy wife, happy life . . . right?!

To view both perspectives on a Cause Map, click on “Download PDF” above.

 

Root Cause Analysis - Incident Investigation

Waste Released from Gold King Mine

By Renata Martinez

On August 5, 2015 over 3 million gallons of waste was released from Gold King Mine into Cement Creek which then flowed into the Animas River. The orangish colored plume moved over 100 miles downstream from Silverton, Colorado through Durango reaching the San Juan River in New Mexico and eventually making its way to Lake Powell in Utah (although the EPA stated that the leading edge of the plume was no longer visible by the time it reached Lake Powell a week after the release occurred).

Some of the impacts were immediate.  No workers at the mine site were hurt in the incident but the collapse of the mine opening and release of water can be considered a near miss because there was potential for injuries. After the release, there were also potential health risks associated with the waste itself since it contained heavy metals.

Water sources along the river were impacted and there’s potential that local wells could be contaminated with the waste.   To mitigate the impacts, irrigation ditches that fed crops and livestock were shut down.  Additionally, the short-term impacts include closure of the Animas River for recreation (impacting tourism in Southwest Colorado) from August 5-14.

The long-term environmental impacts will be evaluated over time, but it appears that the waste may damage ecosystems in and along the plume’s path. There are ongoing investigations to assess the impact to wildlife and aquatic organisms, but so far the health effects from skin contact or incidental ingestion of contaminated river water are not considered significant.

“Based on the data we have seen so far, EPA and the Agency for Toxic Substances and Disease Registry (ATSDR) do not anticipate adverse health effects from exposure to the metals detected in the river water samples from skin contact or incidental (unintentional) ingestion. Similarly, the risk of adverse effects to livestock that may have been exposed to metals detected in river water samples from ingestion or skin contact is low. We continue to evaluate water quality at locations impacted by the release.”

The release occurred when the EPA was working to stabilize the existing adit (a horizontal shaft into a mine which is used for access or drainage). The force of the weight of a pool of waste in the mine overcame the strength of the adit, releasing the water into the environment.  The  EPA’s scope of work at Gold King Mine also included assessing the ongoing leaks from the mine to determine if the discharge could be diverted to retention ponds at the Red and Bonita sites.

The wastewater had been building up since the adit collapsed in 1995.  There are networks and tunnels that allow water to easily flow between the estimated 22,000 mine sites in Colorado.  As water flows through the sites it reacts with pyrite and oxygen to form sulfuric acid.  When the water is not treated and it contacts (naturally occurring) minerals such as zinc, lead, cadmium, copper and aluminum and breaks down the heavy metals, leaving tailings.  The mines involved in this incident were known to have been leaking waste for years.  In the 90s, the EPA agreed to postpone adding the site to the Superfund National Priorities List (NPL), so long as progress was made to improve the water quality of the Animas River.  Water quality improved until about 2005 at which point it was re-assessed.  Again in 2008, the EPA postponed efforts to include this area on the NPL.  From the available information, it’s unclear if this area and the waste pool would have been treated if the site was on the NPL.

In response, the “EPA is working closely with first responders and local and state officials to ensure the safety of citizens to water contaminated by the spill. ” Additionally, retention ponds have been built below the mine site to treat the water and continued sampling is taking place to monitor the water.

So how do we prevent this from happening again?  Mitigation efforts to prevent the release were unsuccessful.  This may have been because the amount of water contained in the mine was underestimated.  Alternatively, if the amount of water in the mine was anticipated (and the risk more obvious) perhaps the excavation work could have been planned differently to mitigate the collapse of the tunnel.  As a local resident, I’m especially curious to learn more facts about the specific incident (how and why it occurred) and how we are going to prevent this from recurring.

The EPA has additional information available (photos, sampling data, historic mine information) for reference: http://www2.epa.gov/goldkingmine