Category Archives: Root Cause Analysis – Incident Investigation

Root Cause Analysis - Incident Investigation

Years of Uncontrolled Leakage Lead to Fatal Mall Collapse

By ThinkReliability Staff

The problems that led to the collapse of a shopping mall’s parking structure were present over its thirty-plus year history says the Report of the Elliot Lake Commission of Inquiry. Multiple opportunities to fix the problem were missed, culminating in the deaths of two on June 23, 2012. Says the report, “Although it was rust that defeated the structure of the Algo Mall, the real story behind the collapse is one of human, not material failure.”

Yes, corrosion of a connection supporting the parking garage decreased its strength to 13% of its original capacity, meaning that on that fateful day, one car driving over it resulted in its fatal collapse. But the more important story is that of how the corrosion was allowed to increase unchecked, due to leakage that had been noted since the opening of the mall.

Multiple causes were discovered resulting in the fatal collapse. The report that addresses them and suggests improvement is more than 1,000 pages long. Though the detail in the report is outstanding, an overview of the information from the report can be diagrammed in a Cause Map, or visual root cause analysis, allowing a one-page overview that clearly shows the cause-and-effect relationships.

It’s important to begin with the impact to the goals. Doing so gives a starting point – and focus – to the cause-and-effect questioning. In this case, the safety goal was impacted due to the 2 fatalities and 19 injuries caused by the collapse. The mall experienced severe damage, and the rescue and response efforts were comprehensive and time-consuming. Additionally, an engineer was criminally charged due to negligence from issues with the mall’s structural integrity.

The fatalities, property damage, and rescue efforts all resulted from the catastrophic collapse of the mall’s rooftop parking structure. The collapse was caused by the sudden failure of a connector. Material failure results from stress on an object overcoming the strength of the object. In this case the stress on the object was a single vehicle driving over the connection in question (evidenced by a video of the collapse). The strength of the connection had been significantly reduced due to corrosion, caused by the continuous ingress of water and chlorides on the unprotected beam.

The leakage was found to stem from a faulty initial design of the waterproofing system from construction of the mall in 1979. Specifically, the architect’s suggestions regarding waterproofing were ignored due to cost and land availability concerns, and the waterproofing system was installed during suboptimal weather because of construction delays. After construction, the architect signed off on the design without inspecting the site, beginning the first in a long list of failings that would eventually cost two women their lives.

Over the years, there were multiple warnings (not the least the need to use buckets to collect leaking water on a fairly constant basis) that were never resolved. According to the report, the problem was never fully addressed with maintenance and repairs but rather pushed off with cheap, ineffective repairs or by selling the structure (as happened twice in its history). For the most part, the local government did not investigate complaints or enforce building standards, apparently unwilling to interfere with the operation of a large source of local revenue and employment

When the local government finally did get involved and issued an Order to Remedy in 2009, the building owner appeared to provide deliberately false information that suggested that repairs were underway, leading to a rescinding of the order later that year. After an anonymous complaint in late 2011, an engineer with a suspended license performed a visual-only inspection which had to be signed off by a licensed engineer. After it was signed, the engineer testified that he had changed the contents of the report at the request of the owner, leading to the criminal charges against him for negligence.

Although plenty of failings were discussed in the report, it states very clearly, “This Commission’s role is not to castigate or chastise; its only purpose in finding fault, if it must, is to seek to prevent recurrence. Criticism of prevailing practices serves only to suggest their improvement or, if necessary, elimination.” In the report, the Commission discusses multiple suggestions for improvement – specifically clarifying, enforcing, and providing public information regarding building standards. Hopefully, the lessons learned from this tragic accident will allow for implementation of these solutions to ensure that thirty years of negligence isn’t allowed to cause a fatal building collapse again.

Root Cause Analysis - Incident Investigation

Software Error Causes 911 Outage

By Kim Smiley

On April 9, 2014, more than 6,000 calls to 911 went unanswered.  The problem was spread across seven states and went on for hours.  Calling 911 is one of those things that every child is taught and every person hopes they will never need to do –  and having emergency calls go unanswered has the potential to turn into a nightmare.

The Federal Communications Commission (FCC) investigated this 911 outage and has released a study detailing what went wrong on that day in April.  The short answer is that a software error led to the unanswered calls, but there is nearly always more to the story than a single “root cause”.  A Cause Map, an intuitive format for performing a root cause analysis, can be used to better understand this issue by visually laying out the causes (plural) that led to the outage.

There are three steps in the Cause Mapping process. The first is to define an issue by completing an Outline that documents the basic background information and how the problem impacts the overall goals.  Most incidents impact more than one goal and this issue is no exception, but for simplicity let’s focus on the safety goal.  The safety goal was impacted because there was the potential for deaths and injuries.  Once the Outline is completed (including the impacts to the goals), the Cause Map is built by asking “why” questions.

The second step of the Cause Mapping process is to analyze the problem by building the Cause Map.  Starting with the impacted safety goal – “why” was there the potential for deaths and injuries?  This occurred because more than 6,000 911 calls were not answered.   An automated system was designed to answer the calls and it wouldn’t accept new calls for hours.  There was a bug in the automated system’s software AND the issue wasn’t identified for a significant period of time.  The error occurred because the software used a counter with a pre-set limit to assign calls a tracking number.  The counter hit the limit and couldn’t assign a tracking number so it quit accepting new calls.

The delay in identification of the problem is also important to identify in the investigation because the problem would have been much less severe if it had been found and corrected more quickly.  Any 911 outage is a problem, but one that lasts 30 minutes is less alarming than one that plays out over 8hours.  In this example, the system identified the issue and issued alerts, but categorized them as “low level” so they were never flagged for human review.

The final step in the Cause Mapping process is to develop and implement solutions to reduce the risk of the problem recurring.  In order to fix the issues with the software, the pre-set limit on the timer has been increased and will periodically be checked to ensure that the max isn’t hit again.  Additionally, to help improve how quickly a problem is identified, an alert has been added to notify operators when the number of successful calls falls below a certain percentage.

New issues will likely continue to crop up as emergency systems move toward internet-powered infrastructure, but hopefully the systems will become more robust as lessons are learned and solutions are implemented.  I imagine there aren’t many experiences more frightening than frantically calling 911 for help and having no one answer.

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

Root Cause Analysis - Incident Investigation

Lawsuit Questions the Safety of Guardrails

By Kim Smiley

A whistleblower lawsuit claims that tens of thousands of guardrails installed across the US may be unsafe.  The concern is that the specific design of the guardrail in question, the ET-Plus, can jam when hit and puncture cars, potentially causing injury, rather than curling away as intended.

This issue has more questions than answers at this point, but an initial Cause Map can be built to document what is currently known.  A question mark should be added to any cause that is suspected, but has not been proven with evidence.  As more information, both new causes and evidence, becomes available the Cause Map can easily be expanded to incorporate it.

In this example, the primary concern, both from a safety and regulation standpoint, about the guardrails are centered on a design change made in 2005.  The size of the energy-absorbing end terminal was changed from five inches to four.  The modification was apparently made as a cost-saving measure.   The lawsuit alleges that federal authorities were never alerted to the design change so it never received the required review and approval.  It appears that federal authorities were not alerted until a patent case bought up the issue in 2012.

The reduction in the size of the end terminals may have affected how the guardrails function during auto accidents.  The lawsuit claims that five deaths and other injuries from at least 14 auto accidents can be attributed to the new design of guardrails.  The Federal Highway Administration has stated that the guardrails meet crash-test criteria, but three states (Missouri, Nevada and Massachusetts) are taking the concerns seriously enough to ban further installation of the guardrails pending completion of the investigation.

This issue is a classic proverbial can of worms.  Up to a billion dollars could be at stake in the lawsuit and the man who filed the lawsuit could get a significant cut of the payout.  There are potential testing requirement issues that need to be considered if the guardrails are passing crash tests, but causing injuries.  There are concerns over whether the company properly informed the federal government about design changes, which is a particularly sensitive topic following the recent GM ignition switch issues.  All and all, this should be a very interesting topic to follow as it plays out.

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

Root Cause Analysis - Incident Investigation

Two Firefighters Killed by Rogue Welding

By ThinkReliability  Staff

On March 26, 2014, two firefighters were killed when trapped in a basement by a quickly spreading, very dangerous fire in Boston, Massachusetts. These firefighters appear to have been the first to succumb to injuries directly caused by fire while on the job in 2014. The company that was found responsible for starting the fire has been fined by OSHA for failure to follow safety procedures. Says Brenda Gordon, Occupational Safety and Health Administration (OSHA)’s director for Boston and southeastern Massachusetts, “This company’s failure to implement these required, common-sense safeguards put its own employees at risk and resulted in a needless, tragic fire.”

Every incident that results in a fatality should be carefully investigated. Investigations are used not only for liability and regulatory reasons, but also to develop solutions to reduce the risk of similar fatalities happening in the future. Investigating an incident such as this in a Cause Map, or visual root cause analysis, allows for better solutions by determining all the cause-and-effect relationships that led to the issue.

First it’s important to define how goals were impacted in order to define the scope of the problem. In this case, two firefighters were killed, which impacts the safety goal. In addition, the spread of the fire, damage of nearby buildings and associated civil lawsuits are also impacts to the goals. The OSHA fine of $58,000 for 10 violations of workplace safety regulations is an impact to the regulatory goal. The response to the fire, as well as the multiple investigations, are impacts to the labor/time goal.

Beginning with an impacted goal and asking “Why” questions develops cause-and-effect relationships that explain how the incident occurred. In this case, the firefighters perished when they were trapped by fire. The firefighters were in the basement of a residential building to rescue occupants from a fire, and the fire was so hot and dangerous that the firefighters could not exit, and other firefighters were unable to come to their rescue. Extremely windy conditions spread the fire caused by a welding spark that struck a nearby wood shed.   OSHA investigators note that the company performing the welding did not follow safety precautions (including having a fire watcher and moving welding away from flammable objects) that would have reduced the risk for fire. They cited the lack of an effective fire prevention/ protection program and a lack of training in workplace and fire safety. View the Cause Map by clicking “Download PDF” above.

Ideally the fine levied by OSHA will encourage the company involved to increase its methods of fire protection, not only to protect its own workers, but also to protect the public. In addition, the Boston Fire Department is conducting an internal review to improve firefighter safety. Says Steve MacDonald, spokesman, “What they’re doing is looking at policies and procedures. They’re reviewing everything, reviewing weather, radio communications, anything and everything having to do with the fire.”

On July 5th, another firefighter died after being trapped in a building while looking for occupants during a fire in Brooklyn, New York. On July 9th, a firefighter in Houston, Texas was killed of smoke inhalation inside a burning building. A firefighter died in a building collapse due to fire in New Carlisle, Indiana on August 5, 2014, making a total of 5 firefighters who have died as a direct result of smoke/fire injuries while on the call of duty so far in 2014. In 2013, a total of 30 firefighters were killed on the job, most as the result of the Yarnell Hill fire in Arizona.

Root Cause Analysis - Incident Investigation

Fire at FAA Facility Sparks Flight Havoc

By Kim Smiley 

On Friday September 26, 2014, air traffic was grounded for hours in the Chicago region following a fire in a Federal Aviation Administration facility in Aurora, Illinois. The snarl of flight issues impacted thousands of travelers in the days following the fire as airports struggled to deal with the aftermath of more than 4,000 canceled flights and thousands more delayed.

A Cause Map, a format for performing a visual root cause analysis, can be used to analyze this issue.  To build a Cause Map, the first step is to define the problem by determining how the overall organizational goals are impacted.  In this example, there is a significant customer service impact because thousands of passengers had their travel plans disrupted. The flight cancelations and delays can be considered an impact to the production/schedule goal.  The amount of time and energy needed to address the flight disruptions along with the investigation into the issue would also be impacts to the labor goal.  Once the impacts to the goals are determined, the Cause Map is built by asking “why” questions and visually laying out the answers to show the cause-and-effect relationship.

Thousands of flights were canceled because air traffic control was unable to support them.  Air traffic control couldn’t perform their usual function because there was a fire in a building that provided air traffic support for a large portion of the upper Midwest and it wasn’t possible to quickly provide air traffic support from another location. Focusing on the fire itself first, the fire appears to have been intentionally set by a contractor who worked in the building.  He was able to bring in flammable materials and start a fire without anyone stopping him.  Police are still investigating his motives, but he has been charged with a felony. The building was evacuated once the fire was discovered and employees obviously couldn’t perform their usual duties during that time.  Additionally, the fire damaged equipment so air traffic control functionality could not be quickly restored once the initial crisis was addressed and it was safe to return to the building.

The second portion of the issue is that there wasn’t a way to support air traffic once the building was evacuated.  Once the fire occurred, all flights were grounded because there wasn’t air traffic control support and it was not possible to quickly get air traffic moving again.

The final step in the Cause Mapping process is to develop and implement solutions to reduce the risk of a similar problem.  Law makers have called for an investigation into this issue to see if there is sufficient redundancy in the air traffic control system.  In an ideal situation, a fire or other crisis at any single location would not cripple US air traffic to the extent that this issue did.  The investigation is also looking into the fire and reviewing the security at the facility to see if there should be stricter restrictions put in place, such as ensuring that no employees work alone or searching bags as workers access the site.

This situation is also a strong reminder that organizations need to have a plan in place of what to do in case a failure occurs.  There was a previous fire scare at this same location earlier in 2014 when a smoking ceiling fan resulted in an evacuation and flight delays (see previous blog) that should have prompted some serious consideration of what the contingency plan should be if this facility was ever out of commission.

I was one of those people standing in line for hours at an airport on Friday morning after my flight was canceled.  And I for one would love to see the air traffic control system become more robust and better able to deal with the inevitable hiccups that occur.  It’s impossible to prevent every potential problem and another intentional fire in a FAA facility seems pretty farfetched, but it is possible to have a better plan in place to deal with issues that may arise.  The potential consequences of any single failure can be limited with a good plan and quick implementation of that plan.

Root Cause Analysis - Incident Investigation

Can Airline Seats Get Even Smaller?

By Kim Smiley

Was the experience the last time you flew wonderful?  Did you enjoy all the luxurious amenities like ample elbow room, stretching out your legs, and turning around in the bathroom?  Me neither.  Comfort certainly hasn’t been the top priority as airlines have shrunk seats to cram more passengers onboard, but a new patent application by Airbus really takes things to a whole new level.

They say that a picture is worth a thousand words and I think that is particularly true in this case.  This is a diagram of a patent application for a proposed seat design –

 

I’m not sure about the rest of you, but my backside is sore just thinking about an airplane seat that bears such a strong resemble to a bicycle.

I attempted to build a Cause Map, a visual root cause analysis, in order to better understand how such a design could be proposed because I frankly find it mind-boggling.  The basic idea is that airlines would like to maximize profits and that putting more people on each flight allows more tickets to be sold resulting in more money made.  The average airline seat width has already decreased to about 17 inches from the 18 inches typical for a long-haul airplane seat in the 1970s and 1980s.  Compounding the impact on passengers is the fact that the average passenger has increased during that same time frame.  In general larger bodies are being put in smaller seats, not a recipe for a comfort.

I’m still having a hard time understanding how the correct answer to increasing airline profits is making seats even smaller.  I have to believe that passengers will balk at some point.  At some level of discomfort, a cheap ticket just won’t be cheap enough for me to be willing to endure a truly awful flight.  Even with electronic distractions and snacks, there has to be a point where people would just say no.

There also has to be a number of safety concerns that arise when the size of airplane seats is dramatically decreased.  Survivability in a crash is greatly influenced by seat design because airplane seats are designed to absorb energy and provide head injury protection during an accident.

Just to be clear, there is no plan to actually use this seat design anytime in the near future.  This is just a patent application.  As Airbus spokeswoman, Mary Anne Greczyn said, “Many, if not most, of these concepts will never be developed, but in case the future of commercial aviation makes one of our patents relevant, our work is protected. Right now these patent filings are simply conceptual.” But somebody somewhere still thought this was a good enough idea that it should be patented…just in case.

Root Cause Analysis - Incident Investigation

Children Served Bleach from Reused Milk Jug

By ThinkReliability Staff

For morning snack on September 11, 2014, a substitute teacher’s aide was getting ready to pour water for snack on her first day on the job. Unfortunately, what she poured from a reused plastic milk container was actually a beach solution used for cleaning. The mistake was realized quickly, but not before 28 children and 2 adults ingested some of the bleach. Luckily the concentration was low enough that there were no injuries, although all who ingested the solution were seen at a local hospital.

The substitute teacher’s aide was fired and the school reopened the next day, though the New Jersey Department of Children and Families will be investigating. Clearly serving cleaning solution to children under your care is undesirable. However, firing the person most directly involved without fixing any of the issues that contributed to the mistake may leave an unacceptable risk for the issue to happen again. Although this appeared to be the first time anything like this happened on such a scale in a day care facility, the misuse of cleaning fluid due to confusing containers has happened before. Just this July a woman was given an epidural of cleaning fluid after containers were accidentally switched. (See our blog to learn more.)

Identifying the impacted goals and all the causes that led to those impacted goals allows for more solutions than just firing the person found to be most immediately responsible. The use of a Cause Map, a visual form of root cause analysis, diagrams all the cause-and-effect relationships in order to develop as many solutions as possible so the most effective among them can be implemented.

First the impacts to the goals are identified. The safety goal is impacted because of the potential for injury to the 28 children and 2 adults who drank the bleach solution. The bleach solution was stored in a food container, which can be considered an impact to the environmental goal. The customer service goal is impacted because the children and adults were served bleach solution. The day care worker being fired, and the ongoing investigation by the licensing agency, can both be considered impacts to the regulatory goal. Additionally, the treatment of all 30 who ingested the solution impacts the labor goal.

Beginning with one impacted goal, we ask “why” questions to determine cause-and-effect relationships. In this case, the safety goal impact of potential injury is due to the children and teachers drinking the bleach solution they were served. The bleach solution was served by the fired employee who was apparently unaware that the milk jug actually stored bleach solution. The executive director indicated that the jug was labeled, so this is apparently not an uncommon practice at the site. The question this raises is, why was an old milk jug used to store cleaning solution?

The American Association of Poison Control Centers (AAPCC) says: “DO NOT use food containers such as cups or bottles to store household and chemical products” and “Store food and household chemical products in separate areas. Mistaking one for the other could cause a serious poisoning.” Although the reused container was apparently labeled (though not clearly enough to avoid the mistake), it should never have been reused in the first place. As indicated by the AAPCC, reusing containers between food and cleaning supplies is just too big of a risk. It’s also worth noting that reusing a bottle that contained household chemicals for a different household chemical is another no-no: “Never mix household chemical products together. Mixing chemicals could cause a poisonous gas.” Don’t run the risk at your workplace or home. Don’t reuse food containers for cleaning products or mix cleaning products.   Fortunately the children at this day care center got off without lasting damage in this case.

Root Cause Analysis - Incident Investigation

App Takes Down National Weather Service Website

By Kim Smiley

The National Weather Service (NWS) website was down for hours on August 25, 2014.  Emergency weather alerts such as tornado warnings were still disseminated through other channels, but this issue raises questions about the robustness of a vital website.

This issue can be analyzed by building a Cause Map, a visual format for performing a root cause analysis.  Cause Maps are built by laying out all the causes that contributed to a problem to show the cause-and-effect relationships.  The idea is to identify all the causes (plural), not just THE one root cause.

This example is a good illustration of the potential danger of focusing on a single root cause.  The NWS website outage was caused by an abusive Android app that bogged the site down with excessive traffic.  The app was designed to provide current weather information and it pulled data directly from the forecast.weather.gov website.  The app inadvertently queried the website thousands of times a second because of a programming error and the website was essentially overwhelmed.  It was similar to the denial of service attacks that have been directed at websites such as Bank of America and Citigroup, but the spike in traffic in this case wasn’t deliberate.

It may be tempting to say that the app was the root cause. Or you could be more specific and say the programming error was the root cause.  But labeling either of these “the root cause” would imply that you solved the problem once you fix the software error. The root cause is gone, no more problem…right?  In order to address the issue, NWS installed a filter to block the excessive queries and worked with app developer to ensure the error was fixed, but there are other factors that must be considered to effectively reduce the risk of a similar problem recurring.

One of the things that must be considered in this example is why a filter that blocked denial of service attacks wasn’t already in place.  Flooding a website with excessive traffic is a well-known strategy of hackers.  If an app could accidently take the site down for hours, it is worrisome to consider what somebody with malicious intent could do.  The NWS is responsible for disseminating important safety information to the public and needs a reasonably robust website.  In order to reduce the impact of a similar issue in the future, the NWS needs to evaluate the protections they have in place for their website and see if any other safeguards should be implemented beyond the filter that addressed this specific issue.

If the investigation was focused too narrowly on a single root cause, the entire discussion of cyber security could be missed.  Building a Cause Map of many causes ensures that a wider variety of solutions are considered and that can lead to more effective risk prevention.

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

Root Cause Analysis - Incident Investigation

Explosion Causes Fatality During Hot Work at Fish Processing Plant

By Holly Maher

On July 28, 2014, one contract worker was killed and another seriously injured when an explosion occurred within a fish oil storage tank, blowing the lid off the 30 foot high vessel.  Contractors were on top of the tank, performing required welding on the tank.  The storage tank contained approximately 8 inches of “stickwater” or a slurry of water and fish matter thought to be non-hazardous.

Although the official investigation of this incident continues with participation from both OSHA (Occupational Safety and Health Administration) and the CSB (Chemical Safety Board), we can use a Cause Map to visually lay out the cause and effect relationships known at this point.  As information becomes available, additional causes can easily be added to the Cause Map.

The first step in the Cause Mapping process is to identify the problem by filling out the Outline.  We clarify the date, time, location, and sometimes “what was different about this incident”, which at this point is unknown.  The explosion occurred at ~9:30 on the morning of July 28th, 2014 at a fish processing plant in Moss Point, Mississippi.  The task being performed when the incident happened was welding on the storage tank.  At the bottom of the outline we identify the impact to the goals for the organization, because although you may get many answers to “what is the problem”, the impact to the goals will provide a common starting point for the investigation.  In this case, the primary goal impacted was the fatality and serious injury related to the explosion.  The tank damage and downtime in the facility could also be captured, however we have focused our discussion here on the safety goal impact.

Once we have identified the goals impacted, we can start the analysis by simply asking some “why” questions.  Why was there one contractor fatality and one serious injury?  Because there was an explosion.  Why was there an explosion?  Because there was an ignition source.  Why was there an ignition source? Because contractors were welding on the tank.  “Why” is a great way to get any investigation started, but we also want to expand  the analysis to ensure all the causes are identified (the system of causes, if you will).  In this case, the explosion is caused not just by the ignition source, but also the presence of fuel and the presence of oxygen (think fire triangle).

The ignition source was caused by the welding on the tank, which was being done for repairs and because the workers were unaware of the combustible atmosphere in the tank. The workers were unaware of the combustible atmosphere because there was no atmospheric testing done on the vapor space in the tank because the stickwater was considered to be non-hazardous.  Unlike the oil and gas industry, where the potential for flammable or combustible atmospheres is well known and managed through atmospheric testing, the potential is less well known in industries, such as fish processing, where organic microbiological fluids can release flammable gases, creating a potential risk when doing maintenance work that is spark or heat producing (hot work).   The fuel source for the explosion was methane and hydrogen sulfide being released from the stickwater.  A sample of the material was sent to the lab after the explosion and the presence of these off-gases was identified.  The flammable gases were present because there was 8 inches of stickwater present in the tank.

The Cause Mapping process allows us to identify all the causes related to an incident with the goal of identifying the best solutions to mitigate potential future risk.  Even with this initial analysis, we can start to identify potential solutions to mitigate the risk of this incident occurring again.  Clearly, the potential hazards from flammable atmosphere is not well known in industries with mixtures of water and organic material (e.g. fish processing, pulp processing, potato processing), so lessons learned from this incident, along with others investigated by the CSB, would be worth sharing across the industry.  In addition, requiring atmospheric testing for hot work would mitigate the potential for explosions during these types of maintenance activities. Another option would be to drain and clean the tank prior to welding activities.  These solution could have significant, global impact across all types of hot work activities.

Root Cause Analysis - Incident Investigation

Ice Bucket Challenge Ends in Serious Injuries

By Kim Smiley

In a terrible reminder that awful things can happen at any time, two firefighters were seriously injured helping the Campbellsville University’s marching band raise money for amyotrophic lateral sclerosis (ALS) research by participating in the trendy ice bucket challenge.  If you ever log onto Facebook, you are probably already familiar with the concept behind the ice bucket challenge, but in case you are not a social media fan, the idea behind the ice bucket challenge is that friends tag each other to either donate $100 to an ALS-related charity  or dump a bucket of ice water over their head.  If you choose the ice bucket, you are supposed to take a video or photo as evidence and post it online.

Trying to create an entertaining video of the ice bucket dumping is part of the fun for many of the participants.  In order to make a memorable video to post on social media, the firefighters that were injured used a fire truck ladder to dump ice water on the band from above.  While on the ladder, the firefighters were near high voltage power lines (although they never actually touched the lines) and electricity arced out, injuring four firefighters.  Two firefighters were treated and released, but two were still hospitalized days later.  One was listed as stable, but the other was in critical condition.

This accident clearly illustrates that high voltage can be extremely dangerous even if you don’t touch the equipment. An arc flash can occur when a flashover of electric current leaves its intended path and travels through the air from one conductor to another or to the ground.  The closer a person is when an arc happens, the more dangerous it is.  Arcs are exceptionally hot and can cause very serious injuries and even death from several feet away when high voltage is in use.

The Public Service Commission stated that they will investigate the location to ensure that the power line had the correct clearance from the ground, trees and structures, but initial reports do not indicate any problems with the power poles.  Possible solutions that could be used to reduce the risk of a similar problem in the future are increased education on the risks of high voltage and ensuring that adequate warning signs are in place.

These have been the most dramatic injuries associated with the ice bucket challenge, but there are a slew of videos featuring buckets dropped on heads, slips and a variety of other unintended outcomes that look painful.  If you are considering doing the ice bucket challenge, please remember that a gallon of water weighs over 8 pounds.  A five gallon bucket filled with water is pretty heavy.  Think the plan through carefully before you ask somebody to dump water on you off a balcony because it may end badly.