Tag Archives: fatalities

Root Cause Analysis - Incident Investigation

Emergency Plan Could Have Saved Lives in TX Plant Explosion

by ThinkReliability Staff

Investigations are still ongoing to determine details on what caused the April 17, 2013 explosion in West, Texas (the subject of a previous blog).  The death toll has risen to at least 14, including 10 emergency workers.  Around 200 are believed to be injured.  The deaths were caused by the explosion of the site AND the proximity of the victims to the site.  The emergency workers were on-site fighting a fire (which was the ignition source of the explosion), but many of those injured had no real reason to be in such a proximity that they would be injured.   

Warning systems and emergency notifications may have resulted in some of the non-emergency response victims getting out of harm’s way.  However, warning systems and notifications like those required for other industrial sites including oil refineries and chemical plants are not required at fertilizer plants.  The plant owner did not comment on emergency management plans for the site.  Senator Barbara Boxer of California will attempt to determine if those requirements need to be strengthened. 

However, even if a warning system had provided sufficient protection to keep nearby citizens from harm, the property damage would have been extensive.  Many properties – including homes and schools – nearby were severely damaged in the blast.  This has led some to believe that there should be an enforced geographical buffer between these types of industrial facilities and other types of facilities, like homes and schools.  The mayor of West has suggested that the plant be rebuilt away from populated areas. 

More and more concerns are being raised about the safety of the plant itself – and the safeguards that could have prevented this explosion.  Despite the large amount of potentially explosive ammonium nitrate stored at the plant, the plant did not have a sprinkler system or fire barrier (which may have prevented the fire from igniting the fertilizer).   

Industrial plants such as these are regulated by a host of state and federal agencies, including the Environmental Protection Agency (EPA).  The EPA required a worst-case scenario from the West site, which identified a release from an anhydrous ammonia storage tank.  The risk of fire or explosion, and the storage of ammonium nitrate were not identified in the scenario, provided in 2011.  (The facility was fined in 2006 for not filing its risk management plan.) 

A key concern is the amount of fertilizer (270 tons) that was stored at the site – which was not disclosed with local governments or federal agencies.  Ammonium nitrate can be used as an explosive (~2.4 tons were used in the Oklahoma City bombing in 1995).  The high volume of ammonium nitrate was not known or disclosed to local or federal officials.   

Most of the victims in this incident were first responders – who had reported to the fire, not knowing the risk they were taking.  The facility had not disclosed the dangers on site, had not provided adequate protection from fire, and had provided little in the way of an effective emergency response plan.   

Every industrial site should have an up-to-date risk/emergency management plan.  The plan needs to be updated whenever new hazards are brought on-site or identified.  It is crucial that these plans be developed and shared with local response organizations, such as fire-fighters, so that they can be prepared for any potential issues.  These plans should also include community engagement to provide necessary information to people in the area as to what actions should be taken.  Existing incident investigations for industrial incidents can be used as a basis for creating these plans.  But, you don’t need to wait until you have a problem at your facility.  Taking the lessons learned from disasters that have already taken place can save your facility – and your community – a tot of heartbreak.   

Remember: A smart man learns from his mistakes, but a wise man learns from others’ mistakes. 

Root Cause Analysis - Incident Investigation

Hundreds of Garment Workers Killed in Building Collapse

By ThinkReliability Staff

Hundreds are confirmed dead – with hundreds more still missing – as a result of a building collapse in Bangladesh.  The number of people who were in the building when it collapsed is unclear, due to spotty records.  Some sources have suggested the death toll may surpass 1,000.

We can examine the causes that led to the deaths in a Cause Map, which visually diagrams the cause-and-effect relationships that led to the tragedy.  First, we capture the impacts to the goals, which includes the extremely significant impact to the safety goal due to the high number of deaths as well as many other goals, including compliance, production and the impact to the labor goal resulting from the rescue and recovery operations.

The deaths were caused by the collapse of a building which was partially occupied at the time. The building housed five garment factories, as well as a bank and other shops.  Even though cracks appeared in the building   and inspectors requested evacuation and closure of the building, garment workers were ordered back to work.    The bank was evacuated, and the shops were already closed.  Despite deplorable conditions (brought to the attention first by a building fire last November and now by this tragic collapse),  workers (mainly young women)   can still be found to work in the garment industry because the average wages in the country are so low.  Eight people, including the building owner and engineers, have been charged as a result of the collapse.

The building, which was illegally built 3 stories too high, was not up to code and not approved by the government.  The building was built on wetland and used substandard materials for construction. As a result of this collapse, the government has said it will form a committee to ensure the safety of buildings and workers.  Shops in the US and Europe that sell garments produced in Bangladesh have distanced themselves from the companies housed in the buildings while many consumers call for more oversight from these companies, who utilize cheap labor in Bangladesh to create their goods.  The garment industry accounts for 77% of Bangladesh’s exports.

It is hoped that this recent tragedy will increase the attention paid to worker safety by the government within Bangladesh as well as consumers who buy the end product abroad.

To view the Outline and Cause Map, please click “Download PDF ” above.

Root Cause Analysis - Incident Investigation

Deadly Explosion at Texas Fertilizer Plant

By ThinkReliability Staff

An explosion at a fertilizer plant in West, Texas, destroyed much of the town and killed between 5-15 people.   (Search and rescue is still ongoing.)  At least 160 were injured but that number may increase.  The material involved in the explosion was ammonium nitrate, a popular fertilizer.

Capturing the impacts to the goals as a result of an issue is essential to understanding the true effect.  In this case, the fatalities and injuries were severe.  The property damage, which included the plant, as well as the homes of more than 100 families, was also extensive.  An environmental impact resulted from the release of ammonia, which is a respiratory irritant. There was some level of evacuation, which can be considered an impact to the customer service goal, though the high number of injuries has led some to believe the evacuation was not widespread enough.  Additionally, ongoing search and rescue, and firefighting operations are an impact to the labor goal.

These goals were all impacted due to the explosion at the fertilizer plant.  Ammonium nitrate can explode when ignited at very high temperatures.  In this case, a fire provided the high heat.  We can capture these causes in a Cause Map, or a visual form of root cause analysis.  The cause of the fire itself is as yet unknown, though if that is determined we can add it to the Cause Map as well.

What is known is that efforts to prevent explosion were ineffective.  The plant did not believe that an explosion was possible.  Its internal safety review had a worst-case scenario of a ten-minute ammonia release, causing no injuries.  It is fairly rare that ammonia nitrate explodes; only 17 known cases of unintended ammonia nitrate explosions resulting in fatalities have occurred since 1921.  Firefighters were on scene fighting the fire when the explosion occurred, leading to many responder fatalities and injuries.  Oversight at the facility was limited; OSHA has not inspected the facility for at least the last five years.

It is worth exploring why large amounts of ammonium nitrate were present.  Ammonium nitrate is an inexpensive, effective fertilizer.  It is particularly good at delivering nitrogen to food-bearing plants, like fruit trees.  The use of nitrogen greatly increases the yield of food from these plants.  (It is said to increase the carrying capacity, or number of people who can be supported by a hectare of land – from 1.9 to 4.3.)  Given the shortage of food-growing land, this is certainly important.   However, the benefits must be considered alongside the risk and certainly in the future more oversight of these types of facilities may be needed to protect the public from the process as they benefit from the results.

To view the Outline and Cause Map, please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

The Deadliest Airship Crash in History Wasn’t the Hindenburg

By Kim Smiley

Many people have heard of the Hindenburg, but have you heard of the USS Akron?  The Hindenburg crashed in 1937, killing 35 people. The USS Akron crash four years earlier killed 73, making it the deadliest airship crash in history.

The crash of the USS Akron can be investigated by building a Cause Map, a visual format for performing a root cause analysis.  A Cause Map is built by asking “why” questions to determine what causes contributed to an issue.  The causes are organized on the Cause Map to illustrate the cause-and-effect relationships between them.  Why were 73 people killed?  This occurred because they were onboard the USS Akron, the airship struck the ocean surface, the crew had little time to brace for impact and there were insufficient flotation devices onboard.

The crew was onboard the USS Akron because the airship was operated by the US Navy and was performing a routine mission at the time of the crash.  The airship hit the ocean because it was operating over the ocean and lost altitude in a severe storm.  Why was the airship operating in a storm?  There was no severe weather predicted at the time and a low pressure system unexpectedly developed.  The crew had little time to brace for the impact because they weren’t aware that an impact was imminent.  There was low visibility at the time because it was a stormy, dark night. The barometric altimeter was also showing that the airship was higher than it actually was.  Barometric altimeters are affected by pressure and the low pressure in the storm impacted more than the crew realized.   The lack of life jackets and other floatation devices also contributed to the high number of deaths.  There were no life jackets onboard the airship at the time of the crash and only one rubber raft.  The safety equipment had been given to another airship and had never been replaced.

While few of us plan to operate or build an airship anytime in the near future, the important of keeping sufficient safety gear onboard any vehicle of any kind is an important lesson.  Lack of safety gear is a reoccurring theme in many historical disasters.  For example, the sinking of the Titanic would be a very different story if there had been sufficient lifeboats onboard.  This example might be very different if the crew had been wearing life jackets.  The airship would still have been lost, but there would likely have been fewer casualties.

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

Root Cause Analysis - Incident Investigation

8 Marines Killed During Training Exercise With Live Ammunition

By ThinkReliability Staff

Eight Marines were killed, and seven Marines and sailors were injured, as the result of the unexpected explosion of a 60 mm round inside a mortar tube during a live ammunition training exercise.  While details are still to be determined, it is known that the unexpected explosion of a mortar round led to the deaths and injuries of those participating in a training exercise with a 60 mm round inside a mortar tube.

Though details of the incident are still unknown, we can begin a Cause Map, or visual root cause analysis, diagramming possible causes which remain to be investigated.  As more information becomes available, evidence supporting or excluding potential causes is included on the Cause Map.

We capture the What, When and Where of the incident in the Problem Outline.  In this case, a training accident/ explosion occurred on March 18, 2013 at about 10:00 pm at the Hawthorne Army Depot in western Nevada.  At the time, a mountain training exercise with live ammunition was using a 60 mm round inside a mortar tube.  A traffic accident that may be related has been mentioned in the news, but no detail has been provided.  To ensure that this line of inquiry is followed during the investigation, we can include it in the “different, unusual, unique” line of the problem outline.

Data that is known, such as the types of damage resulting in deaths and injuries, is included with supporting evidence, in this case testimony of the hospital spokesman.  Causes still to be determined, such as whether the mortar round exploded prematurely in the tube, detonated after being fired, or whether more than a single round exploded are included with question marks and joined by “OR”.  When evidence is obtained throughout the investigation related to a given cause, it is included directly beneath the cause it controls.  Along with the unknown method of detonation of the round, it is unknown whether an issue with the firing procedure, a malfunctioning firing device, or a malfunction in the explosive mortar is to blame.

More details should be coming soon since the use of 60 mm mortars is suspended until the review of this incident determines what happened.  At that time, those causes ruled out by evidence can be crossed off (but left on the Cause Map so that others know they were considered and ruled out as more evidence became available).

At that time, solutions that best address the issues that were causally related can be brainstormed, evaluated, and implemented.

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

Root Cause Analysis - Incident Investigation

Hindenburg Crash: The Importance – and Difficulty – of Validating Evidence

By ThinkReliability Staff

Since the Hindenburg explosion in 1937, theories have abounded on what caused the leaking gas and spark that doomed the airship and dozens of passengers.  We discussed some of these theories in our previous blog on the Hindenburg disaster.

In December, 2012, a documentary on the Discovery Channel used new evidence to discuss the most likely cause of the disaster.  Yep, that’s right.  76 years after the original explosion, evidence is still being gathered to help determine what really caused the explosion that killed 36 people.

Sometimes evidence is relatively easy to gather – many pieces of equipment now feed into automatic data collectors, which can provide reams of data about what happened for a specific period of time.  Sometimes, however, evidence is much harder to come by. This is especially the case with fires or explosions which frequently destroy much of the available evidence.

When evidence is hard to come by, it is difficult to determine the exact cause-and-effect relationships that led to an incident.  The best we may be able to do is capture different possibilities in a Cause Map, or visual root cause analysis, and leave the causes that haven’t been validated by evidence as possible causes, indicated by a question mark.

Sometimes, determining the exact cause(s) is important enough to result in painstaking efforts like those performed by a team at the South West Research Institute.  The team created three 1/10-scale models, not a small undertaking when the scale models are over 80 feet in length and is inflated with 200 cubic meters of hydrogen.  They then replicated scenarios described by the various theories by setting fire to, and blowing up, the models.  Additionally, they studied archive footage and eyewitness accounts to increase their understanding of the disaster.

As a result, the team now believes they have determined what happened.  Says Jem Stansfield, an aeronautical engineer and the project lead, “I think the most likely mechanism for providing the spark is electrostatic.”   The spark ignited leaking hydrogen, caused by a broken tensioning wire that punctured a gas cell or a sticking gas valve.

View the updated investigation with the recently released evidence incorporated by clicking “Download PDF” above.

Read our detailed writeup on the Hindenburg investigation.

Or, click here to read more from the blog of the on-air historian and technical advisor to the project (some really cool photos of making and destroying the models are included).

Root Cause Analysis - Incident Investigation

Brazilian Nightclub Fire Kills At Least 238 People

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By ThinkReliability Staff

A pyrotechnics display meant for outdoor use turned deadly at a band concert in a nightclub in Brazil on January 27, 2013.  The pyrotechnics – which were set off by the band – lit the soundproofing on the ceiling and it spread – with little help from non-functioning fire extinguishers.  The large crowd had difficulty leaving the club, which had only one exit blocked by bouncers who thought patrons were trying to leave without paying.

This tragic incident can be examined using a Cause Map, or visual root cause analysis, which visually diagrams all the causes and impacts related to the nightclub fire.  We begin with the impacted goals.  The safety goal was impacted due to the at least 238 people who were killed and 100 who were injured.  The severe fire is an impact to the environment.  People were unable to exit, which can be considered an impact to the customer service goal.  The loss of the use of the nightclub is an impact to the production goal, and the damage is an impact to the property goal.  Additionally, members of the band and owners of the nightclub are being held, potentially to be charged with manslaughter.  This can be considered an impact to the employee goal.

We begin developing cause-and-effect relationships by asking “Why” questions.  People were killed because they were in the nightclub, unable to exit and there was a severe fire.  Questions have been raised about why the nightclub was even in operation, as its licenses were expired.  People were unable to exit because there was only one exit – completely insufficient for a facility of this size and no windows in the bathroom.  Bouncers were blocking the only exit because they believed patrons were trying to leave without paying – nobody had told them of the fire.  Difficulty seeing the exits due to smoke and lost power resulting from the fire complicated matters even more.

The fire began when the pyrotechnics (heat) lit the soundproofing on the ceiling (fuel).  The fire was unable to be put out due to difficulties reaching the ceiling and non-functioning fire extinguishers.  Specific solutions are being debated by lawmakers in Brazil, but it is hoped that this tragedy will draw attention to – and improve – some of the conditions that contributed to this tragedy.

To view the Outline and Cause Map, please click “Download PDF” above.  Click here to read about another building fire.

 

Root Cause Analysis - Incident Investigation

112 Killed in Garment Factory Fire in Bangladesh

By Kim Smiley

At least 112 were killed in a fire at a garment factory in Bangladesh on November 25, 2012. Officials are still investigating what caused the fire, but many disturbing facts about the disaster have already come to light.

This fire can be analyzed by building a Cause Map, a visual root cause analysis.  When constructing a Cause Map, the first step is to fill in an Outline that lays out the basic facts of the incident.  The impacts to the goal are also listed in the Outline and are used as the first box in the Cause Map.  The Cause Map visually lays out the different things that contributed to an issue and shows the cause-and-effect relationship between the different causes.  In this example, the safety goal was the focus because of the number of lives lost.

So many lives were lost because people were working in the garment factory, there was a fire in the factory, workers were unable to quickly leave the factory and the fire burned for a long time.  People were working in a garment factory because this type of factory work is very common in Bangladesh.  Bangladesh is the world’s second largest producer of garments and work in the industry is one of the main sources of stable income available.  About a third of the population of Bangladesh lives in extreme poverty.  Many of the garment workers are also women, who have limited options for employment.   Investigators have not determined what started the fire, but some government officials have speculated that it may have been arson or sabotage.  Workers were unable to get out of the factory quickly because there was only one exit and the stairways were partially blocked by piles of garments.  There were no emergency exits or fire escapes.  The fire burned all night because it was difficult for fire fighters to reach the factory because it wasn’t easily accessible by vehicles.

As sad as this story is, it was nearly a much worst tale.  It was after normal working hours and many workers had already left the factory.  About 1,500 workers were employed at the factory, but only 600 workers remained working overtime.

The factory produced garments for Western companies such as Disney, Sears and Wal-Mart.  It is not clear if companies were aware that their products were being produced in dangerous conditions and there is some confusion with the use of subcontractors, but this fire raises difficult questions. What responsibility do companies have to the workers producing their clothing?  Thousands of garment workers have protested demanding justice for those killed.  This issue is farther complicated by the fact that some workers are grateful for the work and willing to work in substandard conditions because it’s better than the alternatives.

This issue is also reminiscent of a fire that killed 146 garment workers in 1911 in New York City.   The public outrage following the 146 deaths helped lead to many improvements in worker safety in the United States.  Click here to view a previous blog on this incident.

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.

 

Root Cause Analysis - Incident Investigation

The Comet That Couldn’t Fly

By ThinkReliability Staff

“… the most exhaustively tested airplane in history.”

-Expert opinion on the DeHavilland Comet

Today, commercial jet air travel is standard fare. Estimates for the amount of air traffic over the United States in a given day have been in the range of 87,000 flights. With clever planning, clear skies and smooth service, a citizen almost anywhere in the world can get anywhere else by plane in less than 24 hours. But looking back at the history of aviation show us how far safety has come. Consider the DeHavilland Comet, the first commercial jet to reach production. British aviation specialists finalized the Comet’s design with much excitement in 1945 in hopes it would position their industry to establish a revolutionary service in commercial jet flight. Unfortunately, the Comet crashed on January 10th and April 8th in 1954.

What happened? We can identify some of the causes in a Cause Map, or visual root cause analysis.

CAUSE #1: POOR TESTING When you test an extremely heavy object carrying hundreds of people at high speeds thousands of feet above the ground, you would think planning for the worst case scenario would make the most sense. Unfortunately, the Comet tests were performed in tainted conditions on the strongest part of the plane.

Add in the fact that there was no prototype for the plane and you’ve got a test not worth having… and a plane not worth flying.

CAUSE #2: UNEXPECTED PRESSURE Altitude leads to pressure, and pressure puts stress on planes. But this stress wasn’t evenly distributed, and certain parts of the planes’ bodies were unevenly affected. So rather than the expected amount of pressure on the planes, the Comets faced an unforeseen squeeze.  

CAUSE #3: FLYING ABOVE AND BEYOND The Comet flew at twice the speed, height and cabin pressure of any previous aircraft, displaying a rather dangerous amount of ambition.

Combine all of this, Cause Map it, and you’ve got a plane flying under incredible conditions it couldn’t withstand, facing high pressure where it was most vulnerable.

In other words, an airborne recipe for disaster.

FALLOUT #1) SAFETY As expected, the pressure cycle in the planes’ cabins cracked the bodies of the planes. When the planes broke up, the lives of 56 passengers and crew members were lost.

#2) CUSTOMER SERVICE Some British industry institutions have a highly prestigious reputation (the Royal Navy’s impact on British sea travel comes to mind). The loss of the aircraft, though, was a black eye on British Aviation. Aviation historian George Bibel called the Comet an “adventurous step forward and a supreme tragedy.”

#3) MATERIALS/LABOR Effective airplanes have never been cheap, and this was no different. Not only would it cost money to investigate the cause of the accidents, but to replace the airplanes.   

FUTURE SOLUTION The Comet’s tragic crash had one silver lining: the post-crash analysis performed by its designers (including Sir Geoffrey de Havilland) set the precedent for future air accident investigations. In fact, the Comet was redesigned to solve the issues that caused the crashes and would later fly successfully. But by then, Boeing had already taken over most of the commercial jet market.

In the end, the Comet was first in flight but last in the market.

See more aviation cause maps:

Want us to cause map a specific plane crash for you? Tell us in the comments and we’ll pilot our way through it.