Root Cause Analysis - Incident Investigation

Legionnaires’ Disease Outbreak Blamed on Contaminated Cooling Towers

By ThinkReliability Staff

An outbreak of Legionnaires’ disease has affected at least 115 and killed 12 in the South Bronx area of New York City. While Legionnaires’, a respiratory disease caused by breathing in vaporized Legionella bacteria, has struck the New York City area before, the magnitude of the current outbreak is catching the area by surprise. (Because the vaporization is required, drinking water is safe, as is home air conditioning.) It’s also galvanizing a call for actions to better regulate the causes of the outbreak.

It’s important when dealing with an outbreak that affects public health to fully analyze an issue to determine all the causes that contributed to the problem. In the case of the current Legionnaires’ outbreak, our analysis will be performed in the form of a Cause Map, or visual root cause analysis. We begin by capturing the basic information (what, when and where) about the issue in a problem outline. Because the issue unfolded over months, we will reference the timeline (to view the analysis including the timeline, click on “Download PDF”) to describe when the incident occurred. Some important differences to note – people with underlying medical conditions and smokers are at a higher risk from Legionnaires’, and Legionella bacteria are resistant to chlorine. Infection results from breathing in contaminated mist, which has been determined to have come from South Bronx area cooling towers (which is part of the air conditioning and heating systems of some large buildings).

Next we capture the impact to the goals. The safety goal is impacted due to the 12 deaths, and 115 who have been infected. The customer service goal is impacted by the outbreak of Legionnaires’. The environmental and property goals are impacted because at least eleven cooling towers in the area have been found to be contaminated with Legionella. The issue is resulting in increased regulation, an impact to the regulatory goal, and testing and disinfection, which is being performed by at least 350 workers and is an impact to the labor goal.

The analysis begins by asking “why” questions from one of the impacted goals. In this case, the deaths resulted from an outbreak of Legionnaires’ disease. The outbreak results from exposure to mist from one of the contaminated cooling towers. The design of some cooling towers allows exposure to the mist produced. It is common for water sources to contain Legionella (which again, is resistant to chlorine) but certain conditions allow the bacteria to “take root”: the damp warm environment found in cooling towers and insufficient cleaning/ disinfection. The cost of cleaning is believed to be an issue – studies have found that, like this outbreak, impoverished areas are more prone to these types of outbreaks. Additionally, there are insufficient regulations regarding cooling towers. The city does not regularly inspect cooling towers. According to the mayor and the city’s deputy commissioner for disease control, there just hasn’t been enough evidence to indicate that cooling towers are a potential source of Legionnaires’ outbreaks.

Evidence would indicate otherwise, however. A study that researched risk factors for Legionnaires’ in New York City from 2002-2011 specifically indicated that proximity to cooling towers was an environmental risk. A 2010 hearing on indoor air quality discussed Legionella after a failed resolution in 2000 to reduce outbreaks at area hospitals. New York City is no stranger to Legionnaires’; the first outbreak occurred in 1977, just after Legionnaires’ was identified. There have been two previous outbreaks of Legionnaires’ this year. Had there been a look at other outbreaks, such as the 2012 outbreak in Quebec City, cooling towers would have been identified as a definite risk factor.

For now, though the outbreak appears to be waning (no new cases have been reported since August 3), the city is playing catch-up. Though they are requiring all cooling towers to be disinfected by August 20 and plan increase inspections, right now there isn’t even a list of all the cooling towers in the city. Echoing the frustrations of many, Bill Pearson, member of the committee that wrote standards to address the risk of legionella in cooling towers, says “Hindsight is 20-20, but it’s not a new disease. And it’s not like we haven’t known about the risk of cooling towers, and it’s not like people in New York haven’t died of Legionnaires’ before.”

Ruben Diaz Jr., Bronx borough president, brings up a good point for the cities that may have Legionella risks from cooling towers, “Why, instead of doing a good job responding, don’t we do a good job proactively inspecting?” Let’s hope this outbreak will be a call for others to learn from these tragic deaths, and take a proactive approach to protecting their citizens from Legionnaire’s disease.

Root Cause Analysis - Incident Investigation

Unintended Consequences, Serendipity, and Prawns

By ThinkReliability Staff

The Diama dam in Senegal was installed to create a freshwater reservoir. Unfortunately, that very dam also led to an outbreak of schistosomiasis. This was an unintended consequence: a negative result from something meant to be positive.   Schistosomiasis, which weakens the immune system and impairs the operation of organs, is transmitted by parasitic flatworms. These parasitic flatworms are hosted by snails. When the dam was installed, the snails’ main predators lost a migration route and died off. Keeping the saltwater out of the river allowed algae and plants that feed the snails to flourish. The five why analysis of the issue would go something like this: The safety goal is impacted. Why? Because of an outbreak of schistosomiasis. Why? Because of the increase in flatworms. Why? Because of the increase in snails. Why? Because of the lack of snail predators. Why? Because of the installation of the dam.

Clearly, there’s more to it. We can capture more details about this issue in a Cause Map, or visual form of root cause analysis. First, it’s important to capture the impact to the goals. In this case, the safety goal is impacted because of a serious risk to health and the environmental goal is impacted due to the spread of parasitic flatworms. The customer service goal (if we consider customers as all those who get water from the reservoir created by the dam) is impacted due to the outbreak of schistosomiasis.

Beginning with the safety goal, we can ask why questions. Instead of including just one effect, we include all effects to create a map of the cause-and-effect relationships. The serious risk to health is caused by the villagers suffering from schistosomiasis, which can cause serious health impacts. The villagers are infected with schistosomiasis and do not receive effective treatment. Not all those infected are receiving drugs due to cost and availability concerns. The drugs do not reverse the damage already done. And, most importantly, even those treated are quickly reinfected as they have little choice but to continue to use the contaminated water.

The outbreak of schistosomiasis is caused by the spread of parasitic flatworms, which carry the disease. The increase in flatworms is caused by the increased population of snails, which host the flatworms. The snail population increased after the installation of the dam killed off their predators and increased their food supply.

Many solutions to this issue were attempted and found to be less than desirable. Administering medication for treatment on its own wasn’t very effective, because (as described above) the villagers kept getting reinfected. The use of molluscicide killed off other animals in the reservoir as well. Introducing crayfish to eat the snails was derided by environmentalists as they were considered an invasive species. But they were on the right track. Now, a team is studying the reintroduction of the prawns which ate the snails. During the pilot study, the rates of schistosomiasis decreased. In addition, the prawns will serve as a valuable food source. This win-win solution is an example of serendipity and should actually return money to the community. Says Michael Hsieh, the project’s principal investigator and an assistant professor of urology, “The broad potential of this project is validation of a sustainable economic solution that not only addresses a major neglected tropical disease, but also holds the promise of breaking the poverty cycle in affected communities.”

Introducing animals to get rid of other animals can be problematic, as Macquarie Island discovered when they introduced cats to eat their exploding rodent population who ate the native seabirds). (Click here to read more about Macquarie Island.) Further research is planned to ensure the project will continue to be a success. To learn more about the project, click here. Or, click “Download PDF” to view an overview of the Cause Map.

Root Cause Analysis - Incident Investigation

A single human error resulted in the deadly SpaceShipTwo crash

By Kim Smiley

The National Transportation and Safety Board (NTSB) has issued a report on their investigation into the deadly SpaceShipTwo crash on October 31, 2014 during a test flight.  Investigators confirmed early suspicions that the space plane tore apart after the tail boom braking system was released too early, as discussed in a previous blog.  The tail boom is designed to feather to increase the drag and slow down the space plane, but when the drag was applied earlier than expected the additional aerodynamic forces ripped the space plane apart at both high altitude and velocity.  Amazingly, one of the two pilots survived the accident.

Information from the newly released report can be used to expand the Cause Map from the previous blog.  The investigation determined that the pilot pulled the lever that released the braking system too early.  Even though the pilots did not initiate a command to put the tail booms into the braking position, the forces on the tail booms forced them into the feathered position once they were unlocked.  The space plane could not withstand the additional aerodynamic forces created by the feathered tail booms while still accelerating and it tore apart around the pilots.

A Cause Map is built by asking “why” questions and documenting the answers in cause boxes to visually display the cause-and-effect relationships. So why did the pilot pull the lever too early?  A definitive answer to that may never be known since the pilot did not survive the crash, but it’s easy to understand how a mistake could be made in a high-stress environment while trying to recall multiple tasks from memory very quickly.  Additionally, the NTSB found that training did not emphasize the dangers of unlocking the tail booms too early so the pilot may not have been fully aware of the potential consequences of this particular error.

A more useful question to ask would be how a single mistake could result in a deadly crash.  The plane had to be designed so that it was possible for the pilot to pull a lever too early and create a dangerous situation.  Ideally, no single mistake could create a deadly accident and there would have been safeguards built into the design to prevent the tail booms from feathering prematurely.  The NTSB determined the probable cause of this accident to be “failure to consider and protect against the possibility that a single error could result in a catastrophic hazard to the SpaceShipTwo vehicle.”  The investigation found that the design of the space plane assumed that the pilots would perform the correct actions every time.  Test pilots are highly trained and the best at what they do, but assuming human perfection is generally a dangerous proposition.

The NSTB identified a few causes that contributed to the lack of safeguards in the SpaceShipTwo design.  Designing commercial space craft is a relatively new field; there is limited human factors guidance for commercial space operators and the flight database for commercial space mishaps is incomplete. Additionally, there was insufficient review during the design process because it was never identified that a single error could cause a catastrophic failure. To see the recommendations and more information on the investigation, view a synopsis from the NTSB’s report.

To see an updated Cause Map of this accident, click on “Download PDF” above.

Uncategorized

Extensive Contingency Plans Prevent Loss of Pluto Mission

By ThinkReliability Staff

Beginning July 14, 2015, the New Horizons probe started sending photos of Pluto back to earth, much to the delight of the world (and social media).  The New Horizons probe was launched more than 9 years ago (on January 19, 2006) – so long ago that when it left, Pluto was still considered a planet. (It’s been downgraded to dwarf planet now.)  A mission that long isn’t without a few bumps in the road.  Most notably, just ten days before New Horizons’ Pluto flyby, mission control lost contact with the probe.

Loss of communication with the New Horizons probe while it was nearly 3 billion miles away could have resulted in the loss of the mission.  However, because of contingency and troubleshooting plans built in to the design of the probe and the mission, communication was able to be restored, and the New Horizons probe continued on to Pluto.

The potential loss of a mission is a near miss. Analyzing near misses can provide important information and improvements for future issues and response.  In this case, the mission goal is impacted by the potential loss of the mission (near miss).  The labor and time goal are impacted by the time for response and repair.  Because of the distance between mission control on earth and the probe on its way to Pluto, the time required for troubleshooting was considerable owing mainly to the delay in communications that had to travel nearly 3 billion miles (a 9-hour round trip).

The potential loss of the mission was caused by the loss of communication between mission control and the probe.  Details on the error have not been released, but its description as a “hard to detect” error implies that it wasn’t noticed in testing prior to launch.  Because the particular command sequence that led to the loss of communication was not being repeated in the mission, once communication was restored there was no concern for a repeat of this issue.

Not all causes are negative.  In this case, the “loss of mission” became a “potential loss of mission” because communication with the probe was able to be restored.  This is due to the contingency and troubleshooting plans built in to the design of the mission.  After the error, the probe automatically switched to a backup computer, per contingency design.  Once communication was restored, the spacecraft automatically transmits data back to mission control to aid in troubleshooting.

Of the mission, Alice Bowman, the Missions Operation Manager says, “There’s nothing we could do but trust we’d prepared it well to set off on its journey on its own.”  Clearly, they did.

Uncategorized

Trading Suspended on the NYSE for More Than 3 Hours

By ThinkReliability Staff

On July 8, 2015, trading was suspended on the New York Stock Exchange (NYSE) at 11:32 AM. According to the NYSE president Tom Farley, “the root cause was determined to be a configuration issue.” This still leaves many questions unanswered. This issue can be examined in a Cause Map, a visual form of root cause analysis.

There are three steps to the Cause Mapping problem-solving method. First, the problem is defined with respect to the impact to the goals. The basic problem information is captured – the what, when, and where. In a case such as this, where the problem unfolded over hours, a timeline can be useful to provide an overview of the incident. Problems with the NYSE began when a system upgrade to meet timestamp requirements began on the evening of July 7. As traders attempted to connect to the system early the next morning, communication issues were found and worsened until the NYSE suspended trading. The system was restarted and full trading resumed at 3:10 PM.

The impacts to the goals are also documented as part of the basic problem information. In this case, there were no impacts to safety or the environment as a result of this issue. Additionally, there was no impact to customers, whose trades automatically shifted to other exchanges. However, an investigation by the Securities & Exchange Commission (SEC) and political hearings are expected as a result of the outage, impacting the regulatory goal. The outage itself is an impact to the production goal, and the time spent on response and repairs is an impact to the labor/time goal.

The cause-and-effect relationships that led to these impacts to the goals can be developed by asking “why” questions. This can be done even for positive impacts to the goals. For example, in this case customer service was NOT impacted adversely because customers were able to continue making trades even through the NYSE outage. This occurred because there are 13 exchanges, and current technology automatically transfers the trades to other exchanges. Because of this, the outage was nearly transparent to the general public.

In the case of the outage itself, as discussed above, the NYSE has stated it was due to a configuration issue. Specifically, the gateways were not loaded with the proper configuration for the outage that was rolled out July 7. However, information about what exactly the configuration issue was or what checks failed to result in the improper configuration being loaded is not currently available. (Although some have said that the chance of this failure happening on the same date as two other large-scale outages could not be coincidental, the NYSE and government have ruled out hacking.) According to NYSE president Tom Farley, “We found what was wrong and we fixed what was wrong and we have no evidence whatsoever to suspect that it was external. Tonight and overnight starts the investigation of what exactly we need to change. Do we need to change those protocols? Absolutely. Exactly what those changes are I’m not prepared to say.”

Another concern is the backup plan in place for these types of issues. Says Harvey Pitt, SEC Chairman 2001 to 2003, “This kind of stuff is inevitable. But if it’s inevitable, that means you can plan for it. What confidence are we going to have that this isn’t going to happen anymore, or that what did happen was handled as good as anyone could have expected?” The backup plan in place appeared to be shifting operations to a disaster recovery center. This was not done because it was felt that requiring traders to reconnect would be disruptive. Other backup plans (if any) were not discussed. This has led some to question the oversight role of the SEC and its ability to prevent issues like this from recurring.

To view the investigation file, including the problem outline, Cause Map, and timeline, click on “Download PDF” above. To view the NYSE statement on the outage, click here.

Uncategorized

Small goldfish can grow into a large problem in the wild

By Kim Smiley

Believe it or not, the unassuming goldfish can cause big problems when released into the wild.  I personally would have assumed that a goldfish set loose into the environment would quickly become a light snack for a native species, but invasive goldfish have managed to survive and thrive in lakes and ponds throughout the world.  Goldfish will keep growing as long as the environment they are in supports it.  So while goldfish kept in an aquarium will generally remain small, without the constraints of a tank, goldfish the size of dinner plates are not uncommon in the wild. These large goldfish both compete with and prey on native species, dramatically impacting native fish populations.

This issue can be better understood by building a Cause Map, a visual format of root cause analysis, which intuitively lays out the cause-and-effect relationships that contributed to the problem.  A Cause Map is built by asking “why” questions and recording the answers as a box on the Cause Map.  So why are invasive goldfish causing problems?  The problems are occurring because there are large populations of goldfish in the wild AND the goldfish are reducing native fish populations.  When there are two causes needed to produce an effect like in this case, both causes are listed on the Cause Map vertically and separated by an “and”.   Keep asking “why” questions to continue building the Cause Map.

So why are there large populations of goldfish in the wild?  Goldfish are being introduced to the wild by pet owners who no longer want to care for them and don’t want to kill their fish.  The owners likely don’t understand the potential environmental impacts of dumping non-native fish into their local lakes and ponds.  Goldfish are also hardy and some may survive being flushed down a toilet and end up happily living in a lake if a pet owner chooses to try that method of fish disposal.

Why do goldfish have such a large impact on native species?  Goldfish can grow larger than many native species and they compete with them for the same food sources.  In addition, goldfish eat small fish as well as eggs from native species.  Invasive goldfish can also introduce new diseases into bodies of water that can spread to the native species.  The presence of a large number of goldfish can also change the environment in a body of water.  Goldfish stir up mud and other matter when they feed which causes the water to be cloudier, impacting aquatic plants.  Some scientists also believe that large populations of goldfish can lead to algae blooms because goldfish feces is a potential food source for them.

Scientists are working to develop the most effective methods to deal with the invasive goldfish.  In some cases, officials may drain a lake or use electroshocking to remove the goldfish.  As an individual, you can help the problem by refraining from releasing pet fish into the wild.  It’s an understandable impulse to want to free an unwanted pet, but the consequences can be much larger than might be expected. You can contact local pet stores if you need to get rid of aquarium fish; some will allow you to return the fish.

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

Root Cause Analysis - Incident Investigation

Cause-and-Effect: Alcohol Consumption

By ThinkReliability Staff

The human body is a pretty amazing thing. Many of the processes that take place in our body on a regular basis – keeping us breathing, walking and playing video games or skydiving (or both, though hopefully not at the same time) – have not yet been replicated. They’re that complex.

Which of course raises a lot of questions: why do our bodies work the way they do? It also leads to the subset of questions, when x happens, why does y happen? If your question is, when I drink, why do I feel so great, then so lousy, science has the answers for you . . . and yes, we can capture them in a Cause Map!

If your goal for your body is to feel well and behave pretty consistently, then drinking alcohol is going to impact those goals. First, drinking is going to result in a decrease in control of your behavior. The specifics of how this manifest are legion, but I am assured you probably have many examples. Your post-binge feelings are also going to be impacted: most likely your drinking is going to result in a hangover (generally awful feelings centered around your abdomen and head), dehydration and frequent urination. If your goal is not to eat everything in sight without any consideration about what it will do to your waistline, then your diet may also be impacted due to a desire for carbohydrates.

Beginning with one of these goals, we can ask our favorite question: Why? For example, our decrease in behavior control results from the hypothalamus, pituitary gland, and cerebellum being depressed. This decreases inhibitions, ability to think clearly and also releases a whole slew of hormones and dopamine. Additionally, alcohol impacts neurotransmitters which direct emotions, actions and motor skills, so the combination may make you think you can dance on a table . . . but really you can barely walk.

Now about the ill after-effects. That lovely hangover results from your digestive system attempting to detoxify your body from alcohol and the pounding headache caused by dehydration. When your digestive system works to remove alcohol, the byproduct is acetaldehyde and your body doesn’t like it at all. Most of the alcohol from your body is going to be flushed through your bladder. In order to speed its exit, your body redirects all the liquid it can to your bladder, leaving you dehydrated. (That’s also why you have to run the bathroom so many times after drinking.) The whole process of removing alcohol from your body takes energy. In order to direct as much energy towards alcohol removal as possible, your brain shuts down most of your other functions (which doesn’t help with the ability to function). To get that energy back, your body craves food – carbs in particular (grease optional).

With all these bad effects, you may wonder why people drink at all. Well, when you drink, the alcohol depresses some systems as discussed above, resulting in the release of a bunch of hormones and dopamine. These make us feel good (or even fabulous!). That’s why we keep drinking. (There’s also a whole bunch of social pressures which I’m not going to go into here.)

Giving up drinking altogether is difficult, and many people don’t want to. There are, however, ways to minimize the ill effects of drinking. Food in your stomach helps absorb some of the alcohol, so eating before you drink can help. The headache portion of the hangover can be minimized by drinking a lot of water (though that won’t help with the frequent urination issue). AND OF COURSE, drinking does a number on your fine motor control and general behavior, you should never, ever drink and drive or operate other heavy machinery.

To view the Cause Map of what happens when you drink, click on “Download PDF” above. The information used to create this blog is from:

“The Science of Getting Drunk” and

“Every Time You Get Drunk This Is What Happens To Your Body And Your Brain“

Root Cause Analysis - Incident Investigation

Deadly balcony collapse in Berkeley

By Kim Smiley

A 21st birthday celebration quickly turned into a nightmare when a fifth-story apartment balcony collapsed in Berkeley, California on June 16, 2015, killing 6 and injuring 7.  The apartment building was less than 10 years old and there were no obvious signs to the untrained eye that the balcony was unsafe prior to the accident.

The balcony was a cantilevered design attached to the building on only one side by support beams.  A report by Berkeley’s Building and Safety Division stated that dry rot had deteriorated the support beams significantly, causing the balcony to catastrophically fail under the weight of 13 bodies.

Dry rot is decay caused by fungus and occurs when wood is exposed to water, especially in spaces that are not well-ventilated. The building in question was built in 2007 and the extensive damage to the support beam indicates that there were likely problems with the water-proofing done during construction of the balcony.  Initial speculation is that the wood was not caulked and sealed properly when the balcony was built, which allowed the wood to be exposed to moisture and led to significant dry rot. However, the initial report by the Building and Safety Division did not identify any construction code violations, which raises obvious questions about whether the codes are adequate as written.

As a short-term solution to address potential safety concerns, the other balconies in the building were inspected to identify if they were at risk of a similar collapse so they could be repaired. As a potential longer-term solution to help reduce the risk of future balcony collapses in Berkeley as a whole, officials proposed new inspection and construction rules this week.  Among other things, the proposed changes would require balconies to include better ventilation and require building owners to perform more frequent inspections.  Only time will tell if proposed code changes will be approved by the Berkeley City Council, but something should be changed to help ensure public safety.

Finding a reasonable long-term solution to this problem is needed because balconies and porches are susceptible to rot because they are naturally exposed to weather.  Deaths from balcony failures are not common, but there have been thousands of injuries.  Since 2003, only 29 deaths from collapsing balconies and porches have been reported in the United States (including this accident), but an estimated 6,500 people have been injured.

Click on “Download PDF” above to see a Cause Map, a visual format of root cause analysis, of this accident.  A Cause Map lays out all the causes that contributed to an issue to show the cause-and-effect relationships.

Root Cause Analysis - Incident Investigation

Rollercoaster Crash Under Investigation

By ThinkReliability Staff

A day at a resort/ theme park ended in horror on June 2, 2015 when a carriage filled with passengers on the Smiler rollercoaster crashed into an empty car in front of it. The 16 people in the carriage were injured, 5 seriously (including limb amputations). While the incident is still under investigation by the Health and Safety Executive (HSE), information that is known can be collected in cause-and-effect relationships within a Cause Map, or visual root cause analysis.

The analysis begins with determining the impact to the goals. Clearly the most important goal affected in this case is the safety goal, impacted because of the 16 injuries. In addition to the safety impacts, customer service was impacted because of the passengers who were stranded for hours in the air at a 45 degree angle. The HSE investigation and expected lawsuits are an impact to the regulatory goal. The park was closed completely for 6 days, at an estimated cost of ?3 M. (The involved rollercoaster and others with similar safety concerns remain closed.) The damage to the rollercoaster and the response, rescue and investigation are impacts to the property and labor goals, respectively.

The Cause Map is built by laying out the cause-and-effect relationships starting with one of the impacted goals. In this case, the safety goal was impacted because of the 16 injuries. 16 passengers were injured due to the force on the carriage in which they were riding. The force was due to the speed of the carriage (estimated at 50 mph) when it collided with an empty carriage. According to a former park employee, the collision resulted from both a procedural and mechanical failure.

The passenger-filled carriage should not have been released while an empty car was still on the tracks, making a test run. It’s unclear what specifically went wrong to allow the release, but that information will surely be addressed in the HSE investigation and procedural improvements going forward. There is also believed to have been a mechanical failure. The former park employee stated, “Technically, it should be absolutely impossible for two cars to enter the same block, which is down to sensors run by a computer.” If this is correct, then it is clear that there was a failure with the sensors that allowed the cars to collide. This will also be a part of the investigation and potential improvements.

After the cause-and-effect relationships have been developed as far as possible (in this case, there is much information still to be added as the investigation continues), it’s important to ensure that all the impacted goals are included on the Cause Map. In this case, the passengers were stranded in the air because the carriage was stuck on the track due to the force upon it (as described above) and also due to the time required for rescue. According to data that has so far been released, it was 38 minutes before paramedics arrived on-scene, and even longer for fire crews to arrive with the necessary equipment to begin a rescue made very difficult by the design of the rollercoaster (the world record holder for most loops: 14). The park staff did not contact outside emergency services until 16 minutes after the accident – an inexcusably long time given the gravity of the incident. The delayed emergency response will surely be another area addressed by the investigation and continuing improvements.

Although the investigation is ongoing, the owners of the park are already making improvements, not only to the Smiler but to all its rollercoasters. In a statement released June 5, the owner group said “Today we are enhancing our safety standards by issuing an additional set of safety protocols and procedures that will reinforce the safe operation of our multi-car rollercoasters. These are effective immediately.” The Smiler and similar rollercoasters remain closed while these corrective actions are implemented.

Dr. Tony Cox, a former Health and Safety Executive (HSE) advisory committee chairman, hopes the improvements don’t stop there and issues a call to action for all rollercoaster operators. “If you haven’t had the accident yourself, you want all that information and you’re going to make sure you’ve dealt with it . . . They can just call HSE and say, ‘Is there anything we need to know?’ and HSE will . . . make sure the whole industry knows. That’s part of their role. It’s unthinkable that they wouldn’t do that.”

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

Root Cause Analysis - Incident Investigation

Make safeguards an automatic step in the process

By Holly Maher

On the morning of May 13, 2015, a parent was following his normal morning routine on his way to work.  He dropped off his older daughter at school and then proceeded to the North Quincy MBTA (Massachusetts Bay Transportation Authority) station where he boarded a commuter train headed to work.  When he arrived, approximately 35 minutes later, he realized that he had forgotten to drop off his one-year-old daughter at her day care and had left her in his SUV in the North Quincy station parking lot.  The frantic father called 911 as he boarded a train returning to North Quincy.  Thankfully, the police and emergency responders were able to find and remove the infant from the vehicle.  The child showed no signs of medical distress as a result of being in the parked car for over 35 minutes.

Had this incident resulted in an actual injury or fatality, I am not sure I would have had the heart to write about it.  However, because the impact was only a potential injury or fatality, I think there is great value in understanding the details of what happened and specifically how can we learn from this incident.  Unfortunately, this is not an isolated incident.  According to kidsandcars.org, an average of 38 children die in hot cars annually.  About half of those children were accidentally left in the vehicle by a parent, grandparent or caretaker.  While some people want to talk about these incidents using the terms “negligence” or “irresponsibility”, in the cases identified as accidental it is clear the parents were not trying to forget their children.  They often describe going into “autopilot” mode and just forgetting.  How many of us can identify with that statement?

On the morning this incident happened, the parent was following his typical routine.  After dropping off his older child at school, he went into “autopilot” and went directly to the North Quincy MBTA station, parked and left the vehicle to board the train.  His one-year-old daughter was not visible to him at that point because she was in the back seat of the vehicle in a rear facing car seat, as required by law.  Airbags were originally introduced in the 1970s but became more commercially available in the early 1990s.  In 1998, all vehicles were required to have airbags in both the driver and passenger positions.  This safety improvement, which has surely reduced deaths related to vehicle accidents, had the unintended consequence of putting children in car seats in a less visible position to the parents.  The number of hot car deaths has significantly increased since the early 1990s.

On the morning of the incident the ambient conditions were relatively mild, about 59 degrees Fahrenheit.  However, the temperature in a vehicle can quickly exceed the ambient conditions due to what is called the greenhouse effect.  Even with the windows down, the temperature in a vehicle can rise quickly.  80% of that temperature rise occurs within the first 10 minutes.

When the parent arrived at his destination, approximately 35 minutes later, he realized he had forgotten the infant and reboarded a train to return to the North Quincy station.  Thankfully, the parent also called 911 which expedited the rescue of the infant.  The time in the vehicle would obviously have been longer had he not called 911.

One other interesting detail about this incident is that the parent reported that he normally had a “safeguard” procedure that he followed to make sure this didn’t happen, but he didn’t follow it on this particular day.  It is unknown what the safeguard was or why it wasn’t followed.  This certainly makes an interesting point: we don’t follow safeguards when we know something is going to happen, we follow safeguards in case something happens.  As I told my daughter (who didn’t want to wear her seatbelt on the way from school to home because it “wasn’t that far”), you wear your seat belt not because you know you are going to get into an accident, you wear it in case you get into an accident.

The solutions that have been identified for this incident have been taken directly from kidsandcars.org.  They promote and encourage a consistent process to manage this risk not when you know you are going to forget, but in case you forget.  Consider placing something you need (phone, shoe, briefcase, purse) in the rear floor board so that you are required to open the rear door of the vehicle.  Always open the rear door when leaving your vehicle; this is called the “Look before you Lock” campaign.  Consider keeping a stuffed animal in the car seat; when the car seat is occupied, place the stuffed animal in the front seat as a visual cue/reminder that the child is in the car.  Consider implementing a process where the day care or caretaker calls if your child does not show up when expected.  This will minimize the amount of time the child might be left in the car.

For more information about this topic, visit kidsandcars.org.