Tag Archives: environmental

Root Cause Analysis - Incident Investigation

Poisoned Dead Mice Parachuted onto Guam to Kill Snakes

By Kim Smiley

On December 1, 2013, 2,000 dead, poisoned neonatal mice were parachuted onto Guam on a unique mission to fight an invasive species, the brown tree snake. The parachutes are designed to catch in the trees and tempt the snakes, who live in the trees, into eating the mice. The mice are pumped full of acetaminophen, a chemical that the snakes are particularly sensitive to because it affects their blood’s ability to carry oxygen.

There are an estimated 2 million brown tree snakes on Guam so the 2,000 poisoned mice will only impact a very small percentage of the population, but scientists hope that the information they learn from this drop will help them plan larger mice drops in the future.  This is the fourth and largest dead mice drop so far and cost 8 million dollars.  Some of the mice were embedded with data-transmitting radios for this drop which will allow scientists to better gauge the effectiveness of this technique.

While the 8 million dollar price tag sounds high, it’s important to realize that the damage done by the brown tree snakes each year is significant.  Since their accidental introduction to the island, brown tree snakes have destroyed the native ecosystem, decimating the native bird population.  Brown tree snakes are also fantastic climbers and they routinely get into electrical equipment.  They cause an average of 80 power outages a year, resulting in costs as high as $4 million for repairs and lost productivity annually. (See our previous blog for more information.)

Even through the problem of the brown tree snakes is fairly well understood, an effective solution has been difficult to find.  There have been a number of different things tried over the years: snake traps, snake-sniffing dogs and snake-hunting inspectors have all been used, but the snakes have completely over un the island.  As farfetched as it sounds, parachuting dead mice seems to be the most promising solution at present.  It works because the snakes are very sensitive to acetaminophen; they only need to ingest about one-sixth of a standard pill for it to be effective.  This means that non-target animals are unlikely to be heavily impacted by the mice drops.  A pig or dog would need to eat around 500 of the baited mice for the dose to be lethal. One of the concerns is that snakes tend to avoid prey that is already dead, but information from the radio transmitters used in the recent drop should confirm if the mice are an effective bait.

One thing I know for sure, I would have loved to be in the brainstorm meeting the first time someone suggested parachuting dead mice.  This example is a good reminder to all of us to keep an open mind.  Every now and then, the most bizarre solution suggested turns out to be the best.

Root Cause Analysis - Incident Investigation

The Salvage Process of Costa Concordia

By ThinkReliability Staff

On September 16, 2013, the fatally stricken Costa Concordia was lifted upright (known as “parbuckling”) after salvage operations that were the most expensive and involved the largest ship ever. The ship ran aground off the coast of Italy January 13, 2012 (see our previous blog about the causes of the ship running aground) and has been lying on its side for the 20 months since.

The ship grounding had immediate, catastrophic impacts, including the death of 32 people. However, it also had longer term impacts, mainly pollution from the fuel, sewage and other hazardous materials stored aboard the ship. It was determined that the best way to minimize the leakage from the ship would be to return it upright and tow it to port, where it the onboard waste could be emptied and disposed of, then the ship broken up for scrap.

Because a salvage operation of this magnitude (due to the size and location of the ship) had never been attempted, careful planning was necessary. Processes like this salvage operation can be described in a Process Map, which visually diagrams the steps that need to be taken for a process to be completed successfully. A Process Map differs from a Cause Map, which visually diagrams cause-and-effect relationships to show the causes that led to the impacts (such as the deaths and pollution). Whereas a Cause Map reads backwards in time (the impacted goals result from the causes, which generally must precede those impacts), a Process Map reads from left to right along with time. (Step 1 is to the left of, and must be performed before, Step 2.) In both cases, arrows indicate the direction of time.

Like a Cause Map, Process Maps can be built in varying levels of detail. In a complex process, many individual steps will consist of more detailed steps. Both a high level overview of a process, as a well as a more detailed breakdown, can be useful when developing a process. Processes can be used as part of the analysis step of an incident investigation – to show which steps in a process did not go well – or as part of the solutions – to show how a process developed as a solution should be implemented.

In the example of the salvaging of the Costa Concordia, we use the Process Map for the latter. The salvaging process is part of the solutions – how to remove the ship while minimizing further damage and pollution. This task was not easy – uprighting the ship (only the first step in the salvage process) took 19 hours, involved 500 crewmembers from 26 countries and cost nearly $800 million. Other options used for similar situations included blowing up the ship or taking it apart on-site. Because of the hazardous substances onboard – and the belief that two bodies are still trapped under or inside the ship – these options were considered unacceptable.

Instead, a detailed plan was developed to prepare for leakage with oil booms that held sponges and skirts, then installed an underwater platform and 12 turrets to aid in the parbuckling and hold the ship upright. The ship was winched upright using 36 cables and is being held steady on the platform with computer-controlled chains until Spring, when the ship will be floated off the platform and delivered to Sicily to be taken apart.

To view the Process Map in varying levels of detail, please click “Download PDF” above. Or, see the Cause Map about the grounding of the ship in our previous blog.

Root Cause Analysis - Incident Investigation

Sea life Devastated by Molasses Spill

By Kim Smiley

On September 9, 2013, a reported 1,400 tons of molasses was inadvertently spilled into Honolulu Harbor in Hawaii, devastating the sea life.   When I think of ocean spills, pictures of oil-covered animals jump into my mind, but the molasses spill is proving to be potentially just as damaging to the environment.

This incident can be analyzed by building a Cause Map, an intuitive format for performing a root cause analysis.  A Cause Map visually lays out the causes that contribute to an accident to show the cause-and-effect relationships between them so that it’s easier to understand the factors that led to the issue.  Understanding all the causes and not just focusing on a single “root cause” helps broaden the potential solutions that are considered and can lead to a better long term solution. The first step in the Cause Mapping process is to define how the problem impacted the goals and then these impacts are used as the starting point for the Cause Map.

The most obvious impact from the molasses spill is that thousands of fish and other marine life were killed.  They suffocated because the molasses sank and displaced the oxygen- containing seawater in the harbor.  The density of molasses is what makes this spill so different from an oil spill.  Oil is lighter than water and floats on top of the ocean while molasses sinks to the bottom, with devastating effects at all levels in the ocean.  Divers investigating the molasses spill reported that there were no signs of life in the ocean near the spill; all bottom dwellers had been killed.

The fact that molasses sinks also means that there is no practical way to clean it up.  One positive about molasses is that molasses, unlike oil, will mix with water. It sits on the bottom until it is diluted and ocean movements disperse it.  Since the spill occurred in a protected harbor, the ocean movements are weaker and the time frame to move the molasses is longer than it would be in the open ocean, but nature will eventually return oxygen levels in the harbor to life-supporting levels.

The cause of the spill has been reported to be a leaking pipe.  Molasses produced on Hawaii was being pumped into a ship for transportation to the mainland where it was planned for use in animal feed.  During the transfer, the molasses was accidently pumped through a pipe with a leak and nobody noticed before the majority of the molasses had been released into the harbor.  Details about what specifically caused the leak haven’t been released.

There are also other impacts from the spill that are worth considering.  With any environment issue, the cost of the investigation and any clean up that needs to be done is always substantial. Many businesses in the area were also impacted by a drop in tourism because the harbor was closed for about two weeks after the accident and normal tourism levels will probably not return until marine life in the area begins to recover.  There was also a potential safety risk to any swimmers for a time after the accident because the presence of thousands of dead fish could attract predators.

To view an Outline and high level Cause Map of this accident, click on “Download PDF” above.

Root Cause Analysis - Incident Investigation

A Potentially Stinging Situation – Jellyfish Blooms

By Kim Smiley

Jellyfish are some of nature’s most impressive survivors.  They have been around since long before the dinosaurs roamed the earth and continue to thrive.  In some cases, they may even be thriving a little too successfully.  Massive jellyfish blooms can flourish in the right environment and can decimate other species and cause significant damage.

Naturally occurring jellyfish blooms have been around for ages and while they may be inconvenient at times, they aren’t particularly alarming.  The real concern is that manmade conditions may lead to the growth of jellyfish blooms at times or regions that wouldn’t normally see them.  Large numbers of jellyfish can cause a number of serious issues.  Safety is a concern because jellyfish stings are painful and can even be deadly.  Regions that depend on tourism can also be impacted because travelers may avoid areas with large numbers of jellyfish.  Jellyfish have caused damage to ships and buildings when they clog intake lines.  Populations of other species have also been decimated in some areas by jellyfish blooms which can affect commercial fishing operations.

What causes these jellyfish blooms can be explored by building a Cause Map or visual root cause analysis.  A Cause Map intuitively lays out causes that contribute to an issue and shows the cause-and-effect relationships between them.  In this example, the jellyfish blooms grow because jellyfish are well suited for life in low oxygen “dead zones” that are being created in the ocean.

It all starts with fertilizer containing nutrients running into the ocean.  An algae bloom forms as algae feed on the nutrients.  Eventually the nutrients are depleted and the algae dies off leading to the growth of a bacterial bloom as bacteria feed on the dead algae.  The bacterial bloom depletes the oxygen making the region unsuitable for most species.  However, the opportunistic jellyfish can survive and even thrive in low oxygen levels.  Jellyfish are able to rapidly grow and reproduce quickly so the population surges upward in an environment with few predators and little competition.

A few facts so that the reproductive abilities of jellyfish can be fully appreciated: a single female jellyfish can release tens of thousands of eggs per day, and jellyfish are able to double their weight in a single day if food is abundant.

Eating habits of jellyfish also make it very difficult for other species to move back into the region even if oxygen levels increase.  Jellyfish not only compete for the same food as larvae of other species, plankton, they are fond of eating larvae and eggs.  It’s difficult to compete with a species that is both a predator and competitor.

Before anyone has nightmares of huge jellyfish causing wide scale destruction, I should note that researchers have not found evidence that jellyfish are in danger of overrunning the oceans.  But many scientists do believe that human activities have contributed to jellyfish blooms growing in localized areas.  It’s always worth trying to understand how human activities are impacting our environment, especially when a species so well equipped for survival is involved.

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

Root Cause Analysis - Incident Investigation

Contaminated Water Issues Remain at Fukushima

by ThinkReliability Staff

High levels of contaminated water leaving the highly damaged reactors at the Fukushima Daiichi nuclear power plant in Japan are creating issues for the personnel on site, who are working frantically to keep the reactor safe and working towards decommissioning and closing down the site.  Additionally, there is continued concern for the ongoing safety of the site, as the high volume of water could potentially threaten the safety of the reactors.

We can look at these issues in a Cause Map, or visual root cause analysis.  With a Cause Map, the first step is to determine how the issue impacts the organization’s goals.  In this case, we can consider the goals from the perspective of the utility company that owns the power plant.  There is an impact to the safety goal because of the potential risk for another accident, according to the Chairman of the Nuclear Regulatory Authority.  The leakage of contaminated water is an impact to the environmental goal.  There is concern about the lack of a comprehensive plan by the utility, which can be considered an impact to the customer service goal.  The massive construction efforts required to install tanks to store the water are an impact to the property goal and the efforts by the workers to control the flow are an impact to the labor goal.

Once the impacts to the goals have been determined, the next step is asking “Why” questions to determine the cause-and-effect relationships that led to the incident.  In this case, the issues resulting in the high rate of contaminated water needing to be stored are that high rates of water are entering the reactor, becoming contaminated due to the damage inside the buildings from the earthquake and tsunami on March 11, 2011, and the water has to be removed from the building.

The water is entering the buildings because the plant is in the groundwater flow path from the mountains to the ocean and there is insufficient protection to prevent the water accessing the plant.   Severe cracking in the reactor buildings from the earthquake/tsunami are unable to be repaired due to the high residual levels of radioactivity.  The utility rejected plans to build a wall to protect the reactor.  It is believed this is because the utility had planned to dump the water into the ocean.   Additionally, according to the Japan Atomic Energy Commission, the issues from the water weren’t something that were thought of, as the focus was on the nuclear issues.  All involved in the cleanup, including the utility, have had their hands full, so it’s likely something as benign-seeming as water just wasn’t on the list of immediate concerns.

The contaminated water must be pumped out of the building to avoid swamping the cooling systems, which are still needed to remove decay heat that continues to be produced even after the reactors are shut down.  It appears that the original plan was to filter the water and dump it into the ocean, but even after filtering, a high level (about one hundred times the level released from a healthy plant) of tritium would remain.  Public outcry has ended the possibility of being able to dispose of the water that way.  Wastewater pits originally built for this purpose were found last month to be leaking, necessitating the installation of hundreds of tanks for water storage.

For now, the utility workers continue to install tanks to hold the radioactive water.  The task is so overwhelming, it’s not clear if there are any other plans to try and slow the tide of contaminated water.  However, outside experts are attempting to provide assistance.  The International Atomic Energy Agency completed its initial review of the decommissioning plans last month.  The final team report is expected later this month.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause Analysis - Incident Investigation

Collapse of Salt Mine Creates Massive Sinkhole in LA

By Kim Smiley

On August 3, 2012, a massive sinkhole appeared in Assumption Parish, Louisiana that continues to grow and evade easy answers.   About 150 homes were evacuated and residents are still displaced more than seven months later.

What caused a sinkhole to form overnight?

That question can be answered by building a Cause Map, a visual root cause analysis.  In the Cause Mapping process, the first step is to fill in an Outline with the background information for an issue as well as how the problem impacts the goals.  In this example, the sinkhole impacts several goals including the environmental goal, the safety goal because there is a potential for injuries, the financial goal because of the costs associated with the emergency response and remediation of the issue, and the customer service goal because 150 homes have been evacuated for an extended time.  Once the Outline is completed, the next step is to ask “why” questions to find the different causes that contributed to the problem being analyzed.

So why did the sinkhole form?  The sinkhole formed when an underground salt mine collapsed.  This happened because there was a salt mine in the area and a wall of the mine failed.  Salt was mined in the area because there was a large deposit of salt underground and salt mining is profitable since it is used in a wide range of industries.  The wall collapsed because it was too thin to support the pressure because the mine was inadvertently located too close to the edge of the salt deposit.  The mine ended up too near the edge because the location of the salt deposit wasn’t accurately known.  It’s difficult to access salt deposits thousands of feet underground and the mine was permitted in 1982, using 1960s maps of the salt deposit, using technology that was limited compared to what is used today.

There is also a potential for injuries associated with the sinkhole both because it continues to grow and because there is a risk of explosion from the natural gas being released.  The sinkhole has given the underground pockets of natural gas a pathway to the surface. Workers are trying to minimize the danger by flaring the gas off and ensuring there isn’t anywhere it can build up.

The financial impacts of this issue are substantial, both to the community and the mining company.  The salt mining company is in negotiations to buy out the displaced residents and has been providing financial support to them during the evacuation.  The costs of the emergency response are also adding up, not to mention the cost of whatever remediation is necessary once the area becomes stable and the full extent of the issue is known.

The final step of the Cause Mapping process is to develop solutions to prevent the problem from reoccurring.  This is still an ongoing issue, but some steps have already been taken to help prevent future sinkholes from forming.  Advances in technology have already improved understanding of underground deposits and will help in locating future mines.  Another possible solution is regulation changes to require mines to be located farther from the edge deposit.

To view an Outline and a high level Cause Map for this issue, click on “Download PDF” above.

Root Cause Analysis - Incident Investigation

Plan to Control Invasive Snakes with Drop of Dead Mice

By Kim Smiley

Brown tree snakes are an invasive species that was inadvertently introduced to Guam where they have decimated native bird populations and done massive environmental damage.  It’s estimated that there are about two million of these snakes  on the island.  The newest plan of attack in the battle to control the brown tree snake population is to poison the snakes by parachuting dead mice laced with pain killers onto Guam.

The problem of invasive brown tree snakes can be analyzed by building a Cause Map, a visual root cause analysis.  A Cause Map is built by asking “why” questions and adding the causes to intuitively show the cause-and-effect-relationships.  The first step is to identify the goals that are impacted.  In this example, the environmental goal is impacted because the balance of native species on Guam has been altered.  This has happened because the native bird population has been decimated because they have been eaten by an invasive predator, the brown tree snake.  The spider population has also exploded because many of the birds, their main predator, have disappeared.  The snakes also cause significant and expensive power outages on Guam as they climb into electrical equipment.

Brown tree snakes have taken over Guam for several reasons.  First, the snake was accidently introduced to the island, likely as a stowaway in military cargo after World War II.  Once the snake was on the island, it thrived because the species had no major predator on the island, there was little competition for resources, and there was an abundant food source.  There was little competition because Guam had only one other snake species prior to the introduction of the brown tree snake.  The native snake species is blind and significantly smaller, preying mostly on insects.  The brown tree snake had ample food because it is a pretty flexible predator happy to eat birds, lizards, bats and small mammals.  In fact, the brown tree snake has found Guam so hospitable that the snakes grow larger on Guam than in their native habitat where predators are more plentiful and food is more limited.

Presence of these snakes on Guam has caused massive damage.  Nine of twelve native bird species are extinct on the island.  The snakes have also eaten a significantly amount of the small mammal population.  There has also been a huge impact on vegetation on Guam since the snakes have wiped out many of the pollinators.  Scientists have been trying to find ways to improve the situation.

The newest plan involves dropping dead mice laced with pain killers onto Guam.  The pain killers are deadly to the snakes if ingested.  The mice will be attached to something called a flagger, which is two pieces of cardboard attached with a streamer.  The flagger should act like a parachute and catch in the tree canopy, which is where the snakes predominately spend their time.  The hope is that the snakes will then eat the pain killer laced mice, thus reducing their population.  The current plan is to drop about 2,000 mice over an enclosed area to determine if this is an effective method of brown tree snake population control.  If it works, more dead mice could be headed Guam’s way in the future.

To view a Cause Map of the brown tree snake problem and a Process Map of the plan to drop dead mice, click on “Download PDF” above.  To view a similar example about controlling feral cats on Macquarie Island, click here.

 

 

 

Root Cause Analysis - Incident Investigation

Beijing’s “Airpocalypse”

By Kim Smiley

Beijing’s air pollution was at levels considered hazardous to human health for nearly a week during mid-January 2013.  During this event, colorfully dubbed the “airpocalypse”, pollution levels peaked at 755 as measured by the Air Quality Index (AQI).  This value is considered “Beyond Index” because it is well above the 500 which is considered the maximum AQI value.  Any AQI value over 300 is considered hazardous.

This issue can be analyzed by building a Cause Map, an intuitive format for performing a visual root cause analysis.  The first step in building a Cause Map is to fill in an outline with the basic background information.  The impacts to the organizational goals are also listed in the Outline.  In this example, the safety goal is impacted because people are reporting respiratory issues and there is a possibility of long term health problems because millions were exposed to hazardous air pollution.  The customer service goal has also been impacted because of the negatively publicity that the air pollution issues have generated.  The impacts to the goals are used to build the Cause Map by asking “why” questions.

Why were millions exposed to hazardous air pollution?  This happened because there was air pollution produced in and around Beijing and the pollution was trapped in the city.  A number of sources contributed to the air pollution.  There are many coal burning factories in the area and the amount of coal burnt as a heat source has increased recently because of unusually cold weather.  The number of cars in the city is also increasing at an amazing rate, with thousands more added to the city traffic daily.   There is also a lot of construction in the city needed to meet the demands of such a large population. The pollution was trapped in the city because of the city’s geography and the weather.  Beijing sits on a plain and is flanked by hills.  If the wind doesn’t blow in the right direction to push the  pollution out to sea, it will be trapped by the hills and blanket the city, which is what happened in this case.

The final step in the Cause Mapping process is to develop and implement  solutions to prevent the same thing from recurring.  The Chinese government did take several steps to try to mitigate the  immediate problem with the air pollution by limiting the use of cars and temporarily shutting down some factories.  The pollution finally cleared up as the wind began to blow, but continued efforts will be needed to prevent similar issues in the future.

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

Root Cause Analysis - Incident Investigation

40 Percent of Food in America is Wasted

By Kim Smiley

A report by the Natural Resources Defense Council found that a shocking 40 percent of food in America is wasted.  This means that a huge amount of resources are being used to produce food that is never eaten.  Even worse, this food is left to rot in landfills, which produces the greenhouse gas methane.   Landfills are responsible for 34 percent of all methane emissions in thee United States.

This issue can be analyzed by building a Cause Map, a visual format for performing a root cause analysis.  The first step in Cause Mapping is to fill in an Outline with all the basic information and determine the goals that are impacted.  In this example, the environmental goal is impacted because of the increase of greenhouse gases in the atmosphere and the production goal is impacted because $165 billion of food wasted in United States this year.  Once the impacts are determined, the Cause Map is built by asking “why” questions and adding the answers until the cause-and-effect relationships between all the factors that contributed to an issue are clear.

Starting with the environmental goal, the next step is to ask “why” greenhouse gases are being produced.  Methane, a greenhouse gas, is being produced by the tons of food rotting in landfills.  Tons of food is in landfills because 40 percent of the food in the United States is wasted and that is generally where it ends up.  There is such a large amount of  food waste because there is waste at every step of the food chain and there is little motivation to stop wasting food.  There isn’t sufficient motivation to curb the waste because food is relatively cheap and plentiful in this country.  People are also unaware of the scope of the problem and don’t realize that rotting food is a significant environmental issue.

There are a number of reasons that food is wasted at the different steps in the food chain.  About seven percent of food in the United States never even leaves the field.  A number of things cause this, such as more crops being planted than needed to hedge against bad weather or disease, fluctuating food prices making the harvest prohibitively expensive, and produce that doesn’t meet the size and color standards.   There is a lot of waste post-harvest because edible food is culled that doesn’t always meet the high aesthetic standards of this country.  Grocery stores’ practices also result in a lot of wasted food because they overstock products so they don’t look empty and toss a lot of food that is near or at its sell by dates.  Food services and restaurants also contribute to food waste.  It’s estimated that seventeen percent of the food is left on plates by diners, partly because of the ever increasing portion sizes.  Finally, it’s worth note how much food is wasted in the average American household.  It’s estimated that families throw out between 14 and 25 percent of all food and beverages they purchase.

There will always be some waste associated with food production, but there are simple ways to improve.  Better meal planning, eating more leftovers, lower aesthetic standards for produce, and better understanding of sell by dates by consumers would all help.

Root Cause Analysis - Incident Investigation

Deadly Superstorm Slams the US

By Kim Smiley

Hurricane Sandy pummeled the Mid-Atlantic region of the United States on October 29th  and 30th, 2012, leaving more than eight million people without electricity, causing massive flooding and killing over 110 people.  The damage done by this storm was massive and economic impacts have been predicted to be as high as 50 billion dollars.

Why was Sandy so devastating?  This question can be answered by building a Cause Map, an intuitive format for performing a root cause analysis.  A Cause Map is a useful tool for breaking down this complicated issue and can help explain why this storm was unique.

In this example, there are a number of things that combined to made Sandy a unique and especially dangerous storm.  First off, Sandy wasn’t just a normal hurricane.  As hurricane Sandy moved to the north it converged with other weather systems turning into a hybrid storm.  This hybrid storm brought with it a combination of extreme summer weather (strong winds with heavy rains) and winter weather (cold temperatures and snow).  Unusual timing of the different weather systems helped this superstorm form.  Hurricane Sandy hit very late in hurricane system and cold air sweeping down from Canada was colder than typical for this time of year, a combination that proved deadly.  The nature of these converging weather patterns also made Sandy a very slow moving storm so that areas experienced higher rain fall and more damage than they might have with a faster moving system.

Normal hurricanes are powered by the warm, moist tropical air and weaken as they travel north.  They also typically turn to the right and head out to sea.  When Sandy converged with the other systems it became an extra-tropical cyclone and actually strengthened as it hit shore.  The effects of these other weather systems also turned the storm left onto land and it took an unusual path over some of the most heavily populated areas of the US, including NYC,  intensifying the impact of the storm.

The timing of Sandy also impacted the peak flood levels.  Sandy hit during a full moon when tides are at the highest point of the month.  During a full moon, the effects of the moon’s gravity are felt the strongest so tides are higher.  The high winds created by Sandy combined with the full moon resulted in a massive storm surge.

Sandy truly was a Superstorm.  Weather systems that normally don’t exist at the same time converged to create a massive storm that moved in a usual path over one of the most heavily populated regions in the US.  And the storm hit at the worst time of the month for flooding.

For more information click here or here.  To view a high level Cause Map of this issue, click “Download PDF” above.