All posts by Staci Dekunder

The Solution to America’s Most Unexpectedly Dangerous Mammal

By Staci DeKunder 

It’s hard to imagine that the mammal responsible for over 200 human deaths in America each year is the cute, cuddly…. deer.  These beautiful and seemingly harmless animals are hardly malicious.  Instead, they are in the wrong place at the wrong time, resulting in more than one million deer / vehicle collisions each year.  While the drivers have partial responsibility in these collisions, it seems that changes in the food chain have also contributed to this situation.   

In the 1800s, cougars (also called pumas or mountain lions) could be found roaming across the United States and Canada.  However, beginning in the early 1900s, states began implementing bounty programs enticing hunters to kill cougars.  The goal was to protect livestock and humans from these seemingly dangerous animals.  By the 1950s, the cougar population was primarily limited to areas west of the Rocky Mountains.  As the food chain predicts, the absence of a predator resulted in the overpopulation of its prey.  As the deer population increased, the probability for deer / vehicle collisions also increased.  

Expensive solutions have been considered to help decrease the collision rate, including deer culling, contraception and highway crossings.  However, it seems that nature may now be working towards its own natural solution.  As the bounty programs were removed in the 1960s and 1970s, the cougars have slowly begun migrating back towards the east.  A recent study published in Conservation Letters suggests that repopulation of cougars in the Eastern portion of the US could prevent 708,600 deer / vehicle collisions and 155 deaths over the next 30 years.   (The original fear of cougars attacking humans seems unfounded.  According to The Cougar Network, “Cougars are a retreating animal and very wary of people. Within the United States and Canada since 1890, there have been less than 100 attacks on humans, with about 20 fatalities. Encountering a cougar, let alone being attacked, is incredibly rare.”) 

A Cause Map is a helpful tool to dissect the cause-and-effect relationships contributing to a problem or situation.   Starting with the goals that were impacted, the causes and effects can be linked to create a chain.   For this situation, we begin with the safety goal that is impacted by the many fatalities each year.  Asking ‘Why’ questions, we can dig deeper to understand what causes are behind the impacted goal.   

In this case, the fatalities are a result of car collisions with deer.  The collisions are due to two factors: the deer unexpectedly crossing the road and the fact that the driver didn’t see the deer in time to stop.  We can trace each of these causes one at a time, revealing more causes.  The deer unexpectedly crosses the road because deer are moving to new areas.  This is because deer are overcrowded and need to expand their habitat.  The overcrowding is due to the growing deer population, which is due to the decrease in natural deer predators.  This decrease is caused by the decline in the cougar population, which is a result of the bounty programs that were implemented in the early 1900s.  These bounty programs were motivated by fear that the cougars would endanger humans or livestock.   

Going back to the driver’s role in the situation, we see that the driver may not have seen the deer in time due to poor lighting because deer often travel at dawn or dusk, and the driver may not have been paying close enough attention perhaps because they were distracted.   A second goal, property, was also impacted in this situation because the vehicles are damaged or destroyed as a result of the collisions.   

The Cause Map is also helpful in that it allows us to document the evidence and potential solutions directly on the causes that they can impact.   For example, the statistics about the number of collisions each year, fatalities each year, and cougar population changes are included right below the causes that they support.   Similarly, possible solutions are added right above the causes that they can impact.  In this case, deer culling and contraception could help control the deer overcrowding, and special deer highway crossings could help mitigate the deer crossing the road unexpectedly.  However, nature’s solution seems to fit further back in the chain by impacting the cause that is the decrease in the cougar population.   Time will tell if this solution will, in fact, reduce the number of collisions and injuries as predicted. 

To view the initial Cause Map of this issue, click on “Download PDF” above.

Plant Pathogen Threatens California Oak Trees

By Staci DeKunder

We are often overwhelmed by headlines addressing the latest disease outbreak facing the human population. In recent years, we have read with great concern about Ebola, measles, Avian flu, etc. Unfortunately, there is a similar outbreak facing oak trees in California. Sudden Oak Death is responsible for the death of over one million California oak and tanoak trees. And as it turns out, a microscopic pathogen called Phytophthora ramorum (P. ramorum) is behind the disease.

Matteo Garbelotto was one of the first two scientists to discover P. ramorum in 1995. Over 20 years later, scientists understand much more about how this tree killer operates and how it came in contact with the oaks.   P. ramorum thrive in humid environments, and can spread from plant to plant via wind, rain or with help from humans. Some plants are susceptible to the pathogen (like the California oak and the tanoak), and others are merely host carriers (California bay laurel, rhododendron and camellia). When a susceptible plant is infected, the pathogen attacks the tree’s bark, finding pathways into the tree. From there, it blocks the plants ability to circulate water and nutrients. This results in a fast demise for the tree, with symptoms of brown leaves and sap leaking from the bark.   If the pathogen finds a ‘host ‘plant, the plant is not harmed, but the pathogen can easily be transmitted to a nearby susceptible plant.   This is an issue both in nurseries and in the forest.   A simple Process Map can be created to depict how the pathogen wreaks its havoc on the trees.

As with most situations, understanding the problem is an important step to identifying solutions. Prior to discovering the pathogen P. ramorum, scientists were baffled by the bleeding trees. They initially suspected insects, but could find no visible wounds or damage typical of insects. Creating a Cause Map can help analysis the cause-and-effect relationships that are responsible for an impact to the goals. Asking ‘why’ questions beginning with the affected goal helps us to learn about the causes of an event. In this case, the environmental goal was impacted by the death of millions of trees. The hard work of Garbelotto and his fellow scientists showed that the trees were dying because they were exposed to the pathogen P. ramorum AND the fact that the trees were susceptible to its affects. The plants were exposed to the pathogen because the pathogen was carried from nearby plants. This was due to the fact that there were infected plants were located close by AND the presence of a mode of transportation. This mode of transportation could have been wind, rain and / or human transport. The human transport could be a result of people accidentally moving infected plants or soil.   There are infected plants close by because certain plants act as a ‘breeding ground’ for the pathogen AND because the pathogen was accidentally imported to the United States via host plants via the ornamental plant trade in the 1980’s. (Click on “Download PDF” above to see a Process Map and Cause Map of this issue.)

Fortunately, there are several identified solutions that can help minimize the impact of this pathogen. Using the Cause Mapping process, these solutions can be tagged to the specific causes that they impact. Then, a table of solutions can be created so that the owners (and due dates if applicable) can be tracked.   Five solutions are shown on Cause Map to help save the oak trees including: federally regulating the movement of host plants, using caution when moving plants and soil in infected areas, removing some host plants in infected areas, a phosphite spray which can be applied to infected trees and a smartphone application that can help educate and expand the current understanding of infected areas.

How Did a Cold War Nuclear Bomb Go Missing?

By Staci Dekunder

Is there a nuclear bomb lost just a few miles off the coast of Savannah, Georgia? It seems that we will never know, but theories abound. While it is easy to get caught up in the narrative of these theories, it is interesting to look at the facts of what actually happened to piece together the causes leading up to the event. This analysis may not tell us if the bomb is still under the murky Wassaw Sound waters, but it can tell us something about how the event happened.

Around 2 am on February 5, 1958, a training exercise was conducted off the coast of Georgia. This was during the most frigid period of the Cold war, and training was underway to practice attacking specific targets in Russia. During this particular training mission, Major Howard Richardson was flying a B-47 bomber carrying a Mark 15, Mod 0 Hydrogen bomb containing 400 pounds of conventional explosives and some quantity of uranium.

The realistic training mission also included F-86 ‘enemy’ fighter jets. Unfortunately, one of those jets, piloted by Lt. Clarence Stewart, did not see the bomber on his radar and accidentally maneuvered directly into the B-47. The damage to both planes was extensive. The collision destroyed the fighter jet, and severely damaged the fuel tanks, engine, and control mechanisms of the bomber.   Fortunately, Stewart was able to safely eject from the fighter jet. Richardson had a very difficult quest ahead of him: to get himself and his co-pilot safely on the ground without detonating his payload in a heavily damaged aircraft. He flew to the closest airfield; however, the runway was under construction, making the landing even more precarious for the two crew members and for the local community that would have been affected had the bomb exploded upon landing. Faced with an impossible situation, Richardson returned to sea, dropped the bomb over the water, observed that no detonation took place, and returned to carefully land the damaged bomber.

The Navy searched for the bomb for over two months, but bad weather and poor visibility did not make the search easy. On April 16, 1958, the search was ended without finding the bomb. The hypothesis was that the bomb was buried beneath 10 – 15 feet of silt and mud. Since then, other searches by interested locals and the government have still not identified the location of the bomb.   In 2001, the Air Force released an assessment which suggests two interesting points. First, the bomb was never loaded with a ‘detonation capsule’, making the bomb incapable of a nuclear explosion. (Until this time, conventional wisdom suggested that the detonation capsule was included with the bomb.) Second, the report concluded that it would be more dangerous to try to move the bomb than to leave the bomb in its resting place.

While we may never learn the location of the bomb, we can learn from the incident itself. Using a Cause Map, we can document the causes and effects resulting in this incident, providing a visual root cause analysis. Beginning with several ‘why’ questions, we can create a cause-effect chain. In the simplest Cause Map, the safety goal was impacted as a result of the danger to the pilots and to the nearby communities as the result of a potential nuclear bomb explosion. This risk was caused by the bomb being jettisoned from the plane, which was a result of the collision between the fighter jet and the bomber. The planes collided due to the fact that they were performing a training mission to simulate a combat scenario.

More details are uncovered as this event is further broken down to include more information and to document the impact to other goals. The property goal is impacted through the loss of aircraft and the bomb. The bomb is missing because it was jettisoned from the bomber AND because it was never found during the search. The bomb was jettisoned because the pilot was worried that the bomb might break loose during landing. This was due to the fact that the planes collided. The planes collided due to the fact that the F-86 descended onto the top of the B-47 AND because they were in the midst of a training exercise. The fighter jet crashed into the bomber because the bomber was not on radar. The planes were performing an exercise because they were simulating bombing a Russian target, because it was the middle of the Cold War. The search was unsuccessful because the bomb is probably buried deep in the mud AND because the weather and visibility were bad during the search.

Finally, the ‘customer service’ goal is impacted by the fact that the residents in nearby communities are nervous about the potential danger of explosion/radiation exposure. This nervousness is caused by the fact that the bomb is still missing AND the fact that the bomb contained radioactive material, which was due to routine protocol at the time.

Evidence boxes are a helpful way to add information to the Cause Map that was discovered during the investigation. For example, an evidence box stating the evidence from the 2001 Air Force report that the bomb had no detonation capsule has been added to the Cause Map. A Cause Map is a useful tool to help separate the facts from the theories. Click on “Download PDF” above to see the full, detailed Cause Map.

Avoiding Procedure Horrors in Your Little Shop

By Staci DeKunder

Are you singing “Suddenly Seymour”, yet?  In this blog, we take a look at the ever-so-interesting example of a Venus Flytrap.  These fascinating creatures have captured imaginations and inspired many science fiction books, movies and even a musical (Little Shop of Horrors).  When thinking about a Venus Flytrap, the “problem” really depends on the point of view   From the point of view of the fly, the problem is getting eaten for lunch.  From the point of view of the Venus Flytrap, the problem is how to catch its lunch.  Since it’s really only a problem for one of the parties, we will  focus on the question of how, and examine the Process Map as a best practice for documenting the how in your shop.

Process Maps are very useful tools.  Converting a written job procedure or word of mouth instructions into a picture or map can illuminate a complicated process and make it seem quite simple.  Asking how something happens, or how something gets done can provide valuable detail that can be useful for anyone attempting that task now and in the future.  The benefit can include preventing or minimizing incidents that often recur from lack of clarity in a procedure.

To start with, a very simple map can be created that shows the process of a Venus Flytrap eating a fly in 4 steps:  The fly lands in the trap, the trap closes, the plant eats the fly, and the trap opens again.  However, this ‘simple’ process is actually extremely complex.  In his recent article titled “Venus Flytraps Are Even Creepier Than We Thought” (The Atlantic, January 21 , 2016), Ed Yong outlines the process and intricacies of how the carnivorous plant works.  When the fly lands on the Flytrap’s bright red and enticing leaves, a complicated process of chemicals, electrical impulses and physics is kicked off… all with very delicate timing.  The Flytrap’s leaves are covered with sensitive hairs.  If the fly touches those hairs more than once in 20 seconds, it begins a process ensuring its own demise.  A well-timed increase in calcium ions and electrical impulses result in water flowing to the Flytrap’s leaves, causing them to change shape, trapping the fly inside.  At this point, the more the fly struggles, the more problems it creates for itself.  Further stimulating these hairs results in more calcium ions and more electrical impulses, this time resulting in the flow of hormones and digestive enzymes.  Over time, the leaves will create a hermetic seal and fill up with liquid, causing the fly to asphyxiate and die.  Next, the pH level of the fluid inside the trap drops to 2, and the digestive process begins in earnest.  Recent research suggests that chemical sensors on the Flytrap’s leaves can detect the level of digestion of the fly, stimulating the release of more digestive enzymes if needed, or causing the trap leaves to open back up.  The Flytrap is then ready to begin the process again.  As Charles Darwin said, “THIS plant, commonly called Venus’ fly-trap, from the rapidity and force of its movements, is one of the most wonderful in the world.”  (1875. Insectivorous Plants)

This Process Map, while detailed, could surely be broken down into further detail by a entomologist who deeply understands the intricate workings of a Venus Flytrap.  Fortunately for a baby Venus Flytrap, this process map is coded directly into its DNA, so it doesn’t have to rely on anything to know what to do.  Unfortunately for us, work-related tasks are rarely so instinctual.  We rely on job procedures, process maps and word of mouth to learn the best, safest way to get the job done. Ensuring consistency with that transfer of information is key to making sure that incidents and problems are avoided.  Problems that result from poorly defined procedures or work processes can go by many names: procedure not followed, human error, etc.  At the end of the day, the roots (pun intended) of many of these problems are poorly articulated or poorly communicated work processes.  The simple tool of a process map can help minimize these problems by making the steps of the process clear and easy to understand.

Is Having a Lockout/ Tagout (LOTO) Procedure Enough?

By Staci Dekunder

The number of possible types of injuries occurring when performing work on energized equipment is impossible to count.  They can range from burns, to electrical shock, to crush injuries, to cuts/lacerations, and beyond.  In an effort to help eliminate some of these injuries, the OSHA standard for Control of Hazardous Energy (29 CFR 1910.147), more commonly known as lockout/tagout (LOTO), went into effect in 1989.  The purpose of the standard is to help companies establish the practices and procedures needed to prevent injury to workers when they are performing maintenance activities to equipment requiring an energy source.  Any company in violation of the standard is subject to a fine.  It is estimated that in 2013, there were approximately $14 million in federal and state fines, and lockout/tagout was the 5th most frequently violated standard in 2015.

However, the REAL goal of the standard is to keep people safe.  So how is the standard violated?  It can happen in many ways, but this blog takes a look at one specific incident to better understand  how it can happen.  This analysis is based on a case study presented in the article “Lockout/Tagout Accident Investigation” from the August 2014 issue of Occupational Health & Safety.

In this incident, several contractors were working on a project involving a particular switchgear.  Many of these contractors had performed lockout/tagout for the switchgear box related to the projects that they were working on.  After the work began, a worker from a different contractor was asked to clean out part of the switchgear.  Unfortunately, an arc flash occurred when he reached in the switchgear, resulting in burns to his hand and a blow-out injury to his knee.  Fortunately, the employee survived, recovered, and was able to return to his normal life.

A Cause Map can be built to analyze this issue.  The first step in Cause Mapping is to determine how the incident impacted the overall goals.  For this incident, the safety goal was the most obviously impacted goal due to the injuries that the worker sustained.  The goal is always for employees to leave the workplace in the same health in which they arrived.  Additionally, the regulatory goal was impacted since the injuries were severe enough that they were classified as recordable.

The Cause Map is a visual representation of the cause-and-effect relationships that contributed to the incident.  Starting with the impacted safety goal, ‘why’ questions can be asked to identify the key factors that caused the problem.  In this case, the injuries were caused by the fact that an arc flash occurred when the worker reached into the switchgear and he was not wearing personal protective equipment.  The worker was probably not wearing PPE because he thought that the switchgear was de-energized, and this was an effect of the fact that there were locks and tags already on the switchgear.  The arc flash was a result of the fact that the circuit breaker was energized when the worker reached in to clean it.  The circuit breaker was energized because of three factors: a different contractor had put it back in service the night before, the circuit was not tested by the worker, and the worker didn’t do his own lockout procedure.  Each of these problems can be further analyzed to reveal problems with communication, adding the task at the last minute and not including every task in a job safety analysis.

For this situation, and many like it, eliminating a cause anywhere on the map could have minimized the risk of the incident occurring.  For example, had the worker taken the time to put on protective equipment or test the circuit breaker, he might not have been injured.  Similarly, had the other contractors taken the time to update their locks/tags and ensure that they had communicated that the circuit had been reenergized to all interested parties, the worker might not have been injured.  This example demonstrates that having a lockout/tagout procedure is the first step in avoiding injuries.  Ensuring that the procedure is followed in combination with other safety standards is also important to minimize the risk of injury.