Tag Archives: FAA

Root Cause Analysis - Incident Investigation

FAA Proposes Amazon Fine for Hazardous Shipment

By Kim Smiley

The Federal Aviation Administration (FAA) recently proposed fining Amazon $350,000 for shipping a product that allegedly violated hazardous materials regulations. The package in question was shipped by Amazon from Louisville, Kentucky, to Boulder, Colorado and contained a one-gallon container of corrosive drain cleaner with the colorful name Amazing! LIQUID FIRE. During transit, the package leaked and 9 UPS workers were exposed to the drain cleaner and reported a burning sensation. The workers were treated with a chemical wash and experienced no further issues, but this incident highlights issues with improper shipment of hazardous materials.

A Cause Map, a visual root cause analysis, can be built to analyze this issue by visually laying out the cause-and-effect relationships that contributed to the issue.  The first step in the Cause Mapping method is to fill in an Outline.  The top part of the Outline lists the basic background information for the issue, such as the date and time.  The bottom portion of the Outline has a section to list how the problem impacts the overall goals of the organization.  Most problems have more than one impact and this incident is no exception.  For example, the safety goal is impacted because workers were exposed to hazardous chemicals and the regulatory goal is impacted because of the FAA investigation and the proposed fine.

The frequency of the issue is listed on the last line of the Outline.  Identifying the frequency is important because an issue that has occurred a dozen times may likely warrant a more detailed investigation than an issue that has been reported only once.  For this example, Amazon has had at least 24 hazardous materials violations between February 2013 and September 2015 so the concerns about improperly handling hazardous materials goes beyond the issues with this one package.

Once the Outline is completed, the Cause Map is built by starting at one of the impacted goals and asking “why” questions. Starting at the safety goal for this example, the first question would be “why were workers exposed to hazardous chemicals?”. This happened because the workers were handling a package containing hazardous chemicals, a package containing hazardous chemicals leaked, and inadequate precautions were taken to prevent the workers being exposed to the chemicals. When there is more than one cause that contributes to an effect, the causes are listed vertically and separated by an “and”.

To continue building the Cause Map, ask “why” questions for each of the causes already listed. The workers were handling the package because it shipped by air via UPS. Inadequate precautions were taken to prevent exposure to the chemical because workers were unaware that package contained hazardous chemicals. Chemicals leaked because they were not properly packaged.  Why questions should continue to be asked until no more information is known or no useful detail can be added to the Cause Map. To view an intermediate level Cause Map of this issue with more information, click on “Download PDF” above.

The final step in the Cause Mapping process is to use the Cause Map to develop and implement solutions to reduce the risk of the problem reoccurring. More information about what exactly led to improperly packaged and labeled hazardous materials being shipped would be needed to develop useful solutions in this example, but hopefully a fine of this size and the negative publicity it generated will help spark efforts to make improvements.

Root Cause Analysis - Incident Investigation

Rules on Inflight Electronics May be Changing Soon

By Kim Smiley

In welcome news to many airline passengers, it looks like the FAA may soon allow the use of personal electronic devices during the entire duration of flights, including takeoff and landing.  The current restrictions on the use of personal electronics are being reviewed following a recent recommendation by an aviation advisory committee made of up pilots, mechanics, engineers and other aviation experts.

A Cause Map, a visual format for performing a root cause analysis, can be used to analyze this issue.  A Cause Map is built by asking “why” questions and intuitively laying out the many causes that contributed to an issue to show the cause-and-effect relationships.  The first step in the Cause Mapping process is to document the basic background information as well as list how the issue impacts the goals in the an Outline.

One of the major impacts for this example is that there is concern that use of personal electronic devices onboard aircraft may be dangerous and increase the risk of a plane crash.  Currently, the use of personal electronics is allowed once a plane is above 10,000 feet, which is basically the whole flight except landing and takeoff which are considered the most critical portions of the flight.   These restrictions are in place because pilots depend on electronic systems, such as navigation and communications systems, to safely do their job and there is concern about the potential for interference with these vital systems.

How likely it is that dangerous interference could be an actual issue is debated.  There were 75 reports by pilots of suspected electronic device interference between 2003 and 2009, according to the International Air Transport Association.  However, it’s difficult to reproduce interference and it has never been cited as a cause in any airplane accident.  The current ban on the use of electronics also seems to be loosely enforced, raising questions about its necessity and effectiveness.  (A survey by the Consumer Electronics Association also found that nearly a third of airplane passengers said they left on a portable electronic device on a flight during the previous year.)  There seems to be a general consensus that this is low risk issue, but the potentially high consequences if it occurs has made some reluctant to reduce the restrictions.

There are also some non-technical issues that need to be considered with the onboard use of electronics.  There is concern that passengers enthralled with their devices will be distracted and miss important information during preflight safety briefs.  There is also a concern that larger devices, such as laptops, could become a missile hazard and hurt passengers if the plane moves unexpectedly.

If the new recommendations are approved, passengers will be able to use any device that doesn’t transfer data the entire flight, including takeoff and landing.  Passengers would be able to leave all devices turned on, but they would need to set them to airplane mode so that no data is transmitted.  So you won’t be able to make calls on your smartphone or stream video, but you would be able to rock out to music already downloaded or read a book on a kindle.  Larger devices will still need to be stowed during takeoff and landing because nobody wants to be hit with a laptop, but smaller gadgets will be fair game if the new recommendations are adopted.

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