Root Cause Analysis Information

Deadly Train Collision in Poland

March 8, 2012

On March 4, 2012, two passenger trains collided head-on near Szczekociny, Poland killing 16 and injuring 58.  It was Poland’s deadliest train crash in 20 years. An investigation is underway to determine what caused the deadly accident, but an initial Cause Map can be built now and more details can be added as information becomes [...]

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Cruise Ship Loses Power

March 2, 2012

Part of the excitement involved in passenger cruises is access to remote areas of the world.  However, when a ship runs in to trouble, that remoteness can result in extremely difficult conditions.  This was the case on the Costa Allegra, which suffered an engine room fire in the Indian Ocean. Passengers aboard the Costa Allegra [...]

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Honduran Prison Fire

February 23, 2012

How do you know when your solutions haven’t been effective?  When the same problem keeps happening.  Another prison fire claimed 360 lives in Honduras.  This is the third  prison fatal prison fire in nine years, resulting from  chronic overcrowding and understaffing of Honduran jails. Just more than 3 years since over 100 prisoners were killed [...]

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Collapse of Gulf of Maine Cod Population Feared

February 16, 2012

Recent estimates of the Gulf of Maine cod population show that cod is being over fished to the point that the population is at risk of collapse, meaning the numbers become so low the population cannot recover.  Federal regulators are trying to determine the best course of action to protect the fish population which may [...]

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Several Incidents at CA Nuclear Plant Raise Concerns

February 9, 2012

Within a week, three separate incidents occurred at the San Onofre Nuclear Generating Station, located near heavily populated areas, raising new concerns about the safety of the nuclear power plant. This issue can be investigated by building a Cause Map, an intuitive, visual root cause analysis.  The first step in building a Cause Map is [...]

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Prison Fire Kills 103 in 2009

February 1, 2012

On February 9, 2009, a fire and explosion in a seriously overcrowded prison in Honduras resulted in 103 deaths and 25 injuries.  The fire was started from a short circuit from a overheated refrigerator motor, used to store soft drinks for the inmates.  The cell block – which has a capacity of 800 – contained [...]

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1960 Plane Collision over NYC killed 134

January 26, 2012

On December 16, 1960, two planes collided about a mile above Brooklyn, New York.  One plane – United Airlines Flight 826 – was in a holding pattern preparing to descend into Idlewild (now John F. Kennedy International) Airport.  The other plane – TWA Flight 266 – was preparing to descend into LaGuardia.  Since both airports [...]

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Fatal Cruise Ship Accident

January 18, 2012

At least 11 people have been killed – with 24 still missing – after the cruise ship Costa Concordia ran aground on rocks near the island of Giglio, Italy.  The ship was taken  manually up to 4 miles off course on a route not  authorized by the company. This incident can be thoroughly examined in [...]

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Radioactive Release in the 1960s due to Inadvertent Dropping of Nuclear Weapons

January 13, 2012

In the history of nuclear weapons in the U.S., two accidents (or inadvertent drops) of nuclear weapons have resulted in widespread dispersal of nuclear materials.  These two incidents occurred two years apart, within a week.  The incidents had many similarities: in both cases, a B-52 bomber carrying nuclear weapons was damaged in air during an [...]

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Number of Poached Rhinos Hits All Time High

January 5, 2012

Rhinoceros, commonly called rhinos, have long been hunted for their horns.  Three of the five species of rhinos are considered critically endangered.  According to the National Geographic News Watch, at least 443 rhinos were killed in South Africa in 2011, a significant increase from 333 the previous year.  South Africa is home to more than [...]

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