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The Solution to America’s Most Unexpectedly Dangerous Mammal

By ThinkReliability Staff

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.

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Plant Pathogen Threatens California Oak Trees

By ThinkReliability Staff

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.

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Marauding Monkeys Lead to Electrical Outage in Kenya

By ThinkReliability Staff

One monkey managed to cause an electrical outage for all of Kenya – 4.7 million households and businesses – for 15 minutes to more than 3 hours. In order to determine solutions to prevent this from happening again, a thorough analysis of the problem is necessary. We will look at this issue within a Cause Map, a visual form of root cause analysis.

The first step of any problem-solving method is to define the problem. In the Cause Mapping method, the problem is defined with respect to the organization’s goals. In this case, there were several goals that were impacted. If the organization has a goal of ensuring safety of animals, that goal is impacted due to the risk of a fatality or severe injury to the monkey. (In this case, the monkey was unharmed and was turned over to the wildlife service.) The loss of power to 4.7 million businesses and households is an impact to the customer service goal. The nationwide power outage, which lasted from 15 minutes to over 3 hours, is an impact to the production/ schedule goal. Damage to the transformer is an impact to the property goal, and the time required for response and repair is an impact to the labor/ time goal.

The second step of problem-solving is the analysis. Using the Cause Mapping method, cause-and-effect relationships are developed. One of the impacted goals is used as the first effect. Asking “Why” questions is one way to determine cause-and-effect relationships. However, there may be more than one cause required to produce an effect. In this example, the power outage resulted from a cascading effect on the country’s generators. This cascading effect was caused by the loss of a hydroelectric facility, which provides 20% of the country’s electricity, and the unreliability of the power grid, due to aging infrastructure. All of these causes were required for this scenario: had the country had a more reliable power grid or more facilities so that the country was not so dependent on one, the loss of the hydroelectric site would not have resulted in nationwide outage.

Continuing the analysis, the loss of the hydroelectric facility was caused by an overload when a key transformer at the site was tripped. According to the power company, the trip was caused by a monkey falling onto the transformer. (There is also photographic evidence showing a monkey in the area of the transformer.) In order for the monkey to fall onto the transformer, it had to be able to access the transformer. The monkey in this case is believed to have fallen off the roof. How this occurred is still unclear, because the facility is secured by an electric fence designed specifically for protection against “marauding wild animals”.

The last step of problem-solving is to determine solutions, based on the analysis of this problem. The utility says it is “looking at ways of further enhancing security” at all their power plants. Unfortunately, total protection against outages caused by animals is impossible. In the United States, animal-caused outages are believed to cause at least $18 billion in lost economy every year. Just this May, raccoons caused outages to 40,000 in Seattle and 5,600 in Colorado Springs. This year also saw outages caused by squirrels, snakes, starlings and geese. Other unusual outages include work on a transformer causing an outage with economic loss of $118 million in Arizona (see our blog on this subject) and a woman with a shovel who cut internet service to nearly all of Armenia (see our blog on this subject).

Because power outages due to animals and other issues can’t be completely eliminated, ensuring a robust power grid is important to minimize the impact from and duration of outages. Calls for improvements to the aging infrastructure in Kenya have resulted from this incident, but these kinds of solutions require not only the cooperation of the utilities, but the country as a whole.

To view the problem outline and Cause Map for this incident, please click on “Download PDF” above

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How Did a Cold War Nuclear Bomb Go Missing?

By ThinkReliability Staff

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.

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Experts warn that vehicles are vulnerable to cyberattacks

By Kim Smiley 

By now, you have probably heard of the “internet of things” and the growing concern about the number of things potentially vulnerable to cyberattacks as more and more everyday objects are designed to connect to the internet.  According to a new report by the Government Accountability Office (GAO), cyberattacks on vehicles should be added to the list of potential cybersecurity concerns.  It’s easy to see how bad a situation could quickly become if a hacker was able to gain control of a vehicle, especially while it was being driven.

A Cause Map, a visual root cause analysis, can be built to analyze the issue of the potential for cyberattacks on vehicles.  The first step in the Cause Mapping process is to define the problem by filling out an Outline with basic background information as well as how the problem impacts the overall goals.  The Cause Map is then built by starting at one of the goals and asking “why” questions to visually lay out the cause-and-effect relationships. 

In this example, the safety goal would be impacted because of the potential for injuries and fatalities. Why is there this potential? There is the possibility of car crashes caused by cyberattack on cars. Continuing down this path, cyberattacks on cars could happen because most modern car designs include advanced electronics that connect to outside networks and these electronics could be hacked.  Additionally, most of the computer systems in a car are somehow connected so gaining access to one electronic system can give hackers a doorway to access other systems in the car.

Hackers can gain access to systems in the car via direct access to the vehicle (by plugging into the on-board diagnostic port or the CD player) or, a scenario that may be even more frightening, they may be able to gain access remotely through a wireless network.  Researchers have shown that it is possible to gain remote access to cars because many modern car designs connect to outside networks and cars in general have limited cybersecurity built into them. Why cars don’t have better cybersecurity built into them is a more difficult question to answer, but it appears that the potential need for better security hadn’t been identified.

As of right now, the concern over potential cyberattacks on cars is mostly a theoretical one.  There have been no reports about injuries caused by a car being attacked.  There have been cases of cars being hacked, such as at Texas Auto Center in 2010 when a disgruntled ex-employee caused cars to honk their horns at odd hours and disabled starters, but there are few (if any) reports of cyberattacks on moving vehicles.  However, the threat is concerning enough that government agencies are determining the best way to respond to it. The National Highway Traffic Safety Administration established a new division in 2012 to focus on vehicle electronics, which includes cybersecurity. Ideally, possible cyberattacks should be considered and appropriate cybersecurity should be included into designs as more and more complexity is added to the electronics in vehicles, and objects ranging from pace-makers to refrigerators are designed to connect to wireless networks.

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Florida under attack by another invasive species

By Kim Smiley

Florida’s warm climate has made it an appealing home to many invasive species, such as Burmese pythons (see our previous blog) and giant African land snails.  Researchers fear another species, the Nile monitor lizard,  is also threatening native wildlife.  Nile monitor lizards are intimidating reptiles, growing up to 5 feet long, and they are not fussy about what they eat, consuming almost anything smaller than they are.  They will feed on mammals, birds, reptiles, amphibians, fish and eggs. There have even been reports of Nile monitor lizards making a meal out of pet cats.

This issue can be analyzed by building a Cause Map, a visual format for performing a root cause analysis.  A Cause Map visually lays out the cause-and-effect relationships that contribute to an issue so that they are easily understood.  The first step in building a Cause Map is to fill in an Outline to help define the problem.  Basic background information is recorded in the Outline in addition to how the problem impacts the overall goals.  To build a Cause Map, start at one of the impacted goals, start asking “why” questions and add the answers to the Cause Map. For this example, we will focus on the environmental goal.

Invasive Nile monitor lizards impact the environmental goal because they can have a negative impact on native wildlife.  Why? Monitor lizards eat a varied diet and there are permanent breeding populations of these lizards in Florida.  Why are there populations of Nile monitor lizards in Florida? They were introduced into the environment and the number of Nile monitor lizards in the wild quickly increased. (It’s a bit awkward to write out the “why” questions in this way, but click on “Download PDF” above to see how the Cause Map would visually lay out for this example.)

Nile monitor lizards are basically a perfect (or perfectly bad, depending on your point of view) invasive species.  They grow quickly and breed at an early age.  They lay many eggs at once, as many as 60 eggs in a single clutch. Their natural habitat is very similar to southern Florida and they have a tendency to wander over long distances so it isn’t surprising that they would quickly spread from where they were originally introduced into the wild.

Researchers don’t know exactly how Nile monitor lizards were first introduced into the wild, but it typically occurs when pets escape or are released.  Nile monitor lizards are sold as pets.  Often they are small when sold, but they quickly grow large and can be aggressive.  Owners may release their pets into the wild if they become tired of them or are unable to continue caring for the lizards.  It’s easy to see how a small pet lizard may seem like a good idea, but turn out to be a less than ideal roommate when they have grown into a large, active predatory adult lizard, complete with sharp claws and teeth.  Not to mention, the cost of feeding such a pet might be more than anticipated.

Researchers are still working on developing the best methods to control Nile monitor lizard populations in Florida.  (It is unlikely that Nile monitor lizards will ever be eradicated from Florida, but officials hope to control the numbers.)  Three permanent breeding populations of Nile monitor lizards have been identified, one of which is estimated to be hold over 1,000 lizards.

DNA testing has shown that there are actually two distinct species of Nile monitor lizards and all lizards tested in Florida have been determined to be the newly-named West African Nile monitor lizards. West African Nile monitor lizards aren’t likely to spread too far north in Florida and beyond because they aren’t adapted to cold weather.  The other species of Nile monitor lizards is native to a cooler part of Africa and could potentially spread to a wider area if ever introduced into the wild in the United States.

Bottom line: please don’t release any nonnative species anywhere (even goldfish – see our previous blog).  You may think you are doing the right thing for your pet, but invasive species can do massive damage to native wildlife.  Call a pet store or your local fish and wildlife service if you can no longer care for a pet.  You can also help by reporting sightings of nonnative species to your local fish and wildlife services.

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Oil Leaked from shipwreck near Newfoundland

By Kim Smiley

On March 31, 2013, oil was reported in Notre Dame Bay, Newfoundland.  Officials traced the source of the oil back to a ship, the Manolis L, that sank in 1985 after running aground.  The Manolis L is estimated to have contained up to 462 tons of fuel and 60 tons of diesel when it sank and much of that oil is believed to still be contained within the vessel.  Officials are working to ensure the oil remains contained, but residents of nearby communities who rely on tourism and fishing are concerned about the potential for more oil to be released into the environment.

A Cause Map, a visual format for performing root cause analysis, can be built to better understand this issue.  There are three steps in the Cause Mapping process. The first step is to fill out an Outline with the basic background information along with listing how the problem impacts the goals.  There is also space on the Outline to note the frequency of the issue.  For this example, 2013 was the first time oil was reported to be leaking from this particular sunken ship, but there have been 700 at-risk sunken vessels identified in Canadian waters alone.  It’s worth noting this fact because the amount of resources a group is willing to use to address a problem may well depend on how often it is expected to occur.  One leaking sunken ship is a different problem than potentially having hundreds that may require action.

The second step is to perform the analysis by building the Cause Map.  A Cause Map is built by asking “why” questions and laying out the answers to visually show the cause-and-effect relationships.  Once the causes have been identified, the final step is to develop and implement solutions to reduce the risk of similar problems occurring in the future.  Click on “Download PDF” to view an Outline and intermediate level Cause Map for this problem.

In this case, the environmental goal is clearly impacted because oil was released into the environment.  Why? Oil leaked out of a sunken ship because a ship had sunk that contained a large quantity of oil and there were cracks in the hull.  The hull of this particular ship is thin by modern standards (only a half-inch) and it has been sitting in sea water for the last 30 years.  A large storm hit the region right before oil was first reported and it is believed that the hull (already potentially weakened by corrosion) was damaged during the storm.  The Coast Guard identified two large cracks in the ship that were leaking oil during their investigation.

Once the causes of the issue have been identified, the final step is to implement solutions to reduce the risk of future problem.  This is where a lot of investigations get tricky.  It is often easier to identify the problem than to actually solve it. It can be difficult to determine what level of risk is acceptable and how many resources should be allotted to an issue.  The cracks in the hull of the Manolis L have been patched using weighted neoprene sealants and a cofferdam has been installed to catch any oil that leaks out.  The vessel is being monitored by the Canadian Coast Guard via regular site visits and aerial surveillance flights. But the oil remains in the vessel so there is the potential that it could be released into the environment.

Many local residents are fighting for the oil to be removed from the sunken ship, rather than just contained, to further reduce the risk of oil being released into the environment. But removing oil from a sunken ship is very expensive.  In 2013, it cost the Canadian Coast Guard about $50 million to remove oil from a sunken ship off the coast of British Columbia. So far, officials feel that the measures in place are adequate and that the risk doesn’t justify the cost of removing the oil from the vessel. If they are right, the oil will stay safely contained at a fraction of the cost of removing it, but if they are wrong there could be lasting damage to local communities and wildlife.

In situations like this, there are no easy answers.  Anybody who works to reduce risk faces similar tradeoffs and generally the best you can do is to understand a problem as thoroughly as possible to make an informed decision about the best use of resources.

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Track Workers Killed by Train

By ThinkReliability Staff

A derailment and the fatalities of two railroad workers on April 3, 2016 has led to an investigation by the National Transportation Safety Board (NTSB). In this investigation, the NTSB will address the impacts of the accident, determine what caused the accident and will provide recommendations to prevent similar accidents from recurring. While the investigation is still underway, a wealth of information related to the accident is already available to begin the analysis. We will look at what is currently known regarding the accident in a Cause Map, a visual form of root cause analysis.

The first step of the analysis is to define the problem. This includes the what, when, and where of the incident, as well as the impacts to the organizational goals. Capturing the impacts to the goals is particularly important because the recommendations that will result from the analysis aim to reduce these impacts. If we define the problem as simply a “derailment”, recommendations may be limited to those that prevent future derailments. Not only are we looking for recommendations to prevent future derailments, we are looking for recommendations to prevent all the impacted goals. In this case, that includes worker safety: 2 workers died, public safety: 37 passengers were injured, customer service: the train derailed, property: the train and some construction equipment was damaged, and labor: response and investigation are required.

The analysis is performed by beginning with the impacted goals and developing the cause-and-effect relationships that led to those impacts. Asking “why” questions can help to identify some of the cause-and-effect relationships, but there may be more than one cause that results in an effect. In this case, the worker fatalities occurred because the train struck heavy equipment and the workers were in/on/near the equipment. Both of these causes had to occur for the effect to result. The workers were on the equipment performing routine maintenance. In addition, their watch was ineffective. When capturing causes, it’s important to also include evidence, which validates the cause.

We know the watch was ineffective, because federal regulation requires a watch for incoming trains that gives at least a fifteen second warning. Fifteen seconds should have been sufficient time for the workers to exit the equipment. Because this did not happen, it follows that the watch was ineffective.

The train struck the heavy equipment because the equipment was on track 3, the train was on track 3, and the train was unable to brake in time. It’s unclear why the heavy equipment was on the track; rail safety experts say heavy equipment should never be directly on the track. The train was on track 3 because it was allowed on the track. Work crews are permitted to shut off the current to preclude passage of trains into the work zone, but they did not in this case, for reasons that are still being investigated. Additionally, the dispatcher allowed the train onto the track. Per federal regulations, when workers are on the track, train dispatchers may not allow trains on track until roadway worker gives permission. It appears that in this case the workers either failed to secure permission to work on the track (thus notifying the dispatcher of their presence) or the work notification was improperly cancelled, allowing trains to return to the track, possibly due to a miscommunication between the night and day crews. This is also still under investigation.

While inspection of the cars and maintenance records found no anomalies, the braking system is under investigation to determine whether or not it affected the train’s ability to brake. Also under investigation is the Positive Train Control (PTC), which should have emitted warnings and slowed the train automatically. However, the supplemental shunting device, which alerts the signaling system that the track is occupied, and is required by Amtrak rules, was not in place. Whether this was sufficient to prevent the PTC from stopping the train in time is also under investigation. The conductor placed the train in emergency mode 5 seconds before the collision. As the train was traveling at 106 mph (the speed limit was 110 mph in the area), this did not give adequate time to brake. There should have been a flagman to notify the train that a crew was on the track, but was not. The flagman also carries an air horn, which provides another notification to the track crew that a train is coming.

Says Ashley Halsey III, reporting in The Washington Post, “Basic rules of railroading and federal regulations should have prevented the Amtrak derailment near Philadelphia on Sunday that killed two maintenance workers.” It appears that multiple procedural requirements were not followed, but more thorough investigation is required to determine why and what can be done in the future to improve safety by preventing derailments and worker fatalities.

To view the available information in a Cause Map, please click “Download PDF” above.

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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.

 

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Flammable Siding Fuels High Rise Hotel Fire

By ThinkReliability Staff

A fire on New Year’s in Dubai has raised concern with similar building materials across the world. Around 9:30 pm on December 31, 2015, a fire started at a 63-story hotel. The fire quickly spread along the outside of the building. There were no reported fatalities but at least 14 were injured.

Performing a thorough root cause analysis for one specific incident can develop solutions for similar incidents around the world. These types of fires are becoming increasingly common – there have been 8 in the last two decades in Dubai alone. Similar fires have occurred in China, Azerbaijan, and Australia over recent years. We can investigate the causes the led to the New Year’s fire in Dubai by using the Cause Mapping method, a visual form of root cause analysis.

Our analysis begins by capturing the what, when and where of an incident as well as the impacts to the organization’s goals. In this case, the safety goal is impacted due to the injuries. The environmental goal is impacted due to the significant amount of smoke released, and the customer service goal is impacted because of the evacuation. Additional goals impacted include the property damage to the hotel and the labor/time associated with response and repairs.

Beginning with the impact to the safety goal, we can ask “why” questions to capture the cause-and-effect relationships that led to the injuries. In this case, the injuries resulted from an extensive fire that spread up the side of the hotel. An extensive fire requires both initiation and spread. Both the initiation and spread result from heat, fuel and oxygen. The oxygen in both cases was provided by the atmosphere. The heat source for the initiation is believed to be either from exposed wiring (per the local police chief and shown in photographs from before the incident), or a short circuit in a lamp (reported by some news sources). Because it has not been definitively determined, we put a “?” after each cause, and join them with “OR”. The fuel source for the initiation has been reported as curtains. Flammable liquid was also a potential cause but has been ruled out by the police chief.

A burning fire provides heat, so it will continue to burn as long as oxygen and fuel are present. The fuel that allowed the rapid spread of the fire is flammable cladding used as siding. This siding is made of two thin pieces of aluminum surrounding a foam core. Foam cores made primarily of polyethylene are highly flammable. This type of cladding is used because it is considered to provide a modern look, allows dust to be rinsed off during rains, and is relatively simple and cheap to install. While the foam core can be made of flame-resistant materials, this was not required for this building. After a similar fire in Dubai in 2012, new regulations banned the use of flammable material as cladding, but existing buildings (including this hotel) were not required to be retrofitted. The cladding was installed continuously, which allowed the fire to rapidly climb up the side of the building.

While electrical faults that can act as heat sources should be repaired as quickly as possible, the flammability of the materials used on high-rise buildings with multiple potential heat and fuel sources (and a nearly unlimited supply of oxygen) have raised significant concern, not only about this hotel or Dubai, but about buildings with similar cladding around the world. Says Peter Rau, the chief officer of Melbourne, Australia’s Metropolitan Fire Brigade (where a similar fire broke out in November 2014), “You know you’ve only got to step back a little bit further and say: ‘What does it mean for Australia and what does it mean (when) you’re talking to me from Dubai? This is a significant issue worldwide, I would suggest . . . There is no question this is a game changer.”