Tag Archives: fine

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.

First Airline Fine for Tarmac Delay

by Kim Smiley

The Department of Transportation (DOT) recently issued the first fine for violating new rules that limit how long passengers can be kept onboard a plane waiting on the tarmac. The new regulations, commonly called the tarmac delay rule, state that passengers may not be kept onboard a plane waiting on the runway for more than 3 hours without being given the opportunity to deplane.  The rules also require that airlines provide adequate food and drinking water for passengers within 2 hours of a plane being delayed on the tarmac and to maintain operable lavatories.  The tarmac delay rule, which went in effect April 2010, was created following several incidents where passengers were kept onboard airplanes for long periods of time.

The incident that resulted in a fine is not the first violation of the 3 hour rule, but this is the first time the DOT has taken the step of issuing a fine.  The potential fees for violating the rules are substantial.  Airlines can be fined $27,500 per passenger when the tarmac delay is beyond 3 hours.  This quickly adds up, especially if multiple flights are involved.  In this example, 15 American Eagle flights were delayed beyond the 3 hour limit on May 29, 2011 at O’Hare International Airport in Chicago.   608 passengers were affected and American Airlines was fined a whopping $900,000.

What happened?  How were so many flights on the tarmac so long?

This example can be analyzed by building a Cause Map, a method for performing a visual root cause analysis.  A Cause Map is built by determining the cause-and-effect relationships between all the causes that contributed to an incident.  Click on “Download PDF” above to view a high level Cause Map of this incident.

As with many airline delays, inclement weather played a major role in this incident.  Flights had been delayed taking off from O’Hare and planes that were scheduled to have departed were still sitting at the gates.  Planes that landed had nowhere to go so they sat on the tarmac waiting for an open gate.

Passengers were not given an opportunity to deplane within 3 hours.  The airline has procedures to get passengers off the planes even if the planes themselves were stuck waiting on the tarmac, but the procedures were not implemented within the 3 hour time limit.  If there was no delay limit, an airline couldn’t violate it so the new creation of the tarmac delay role is also a cause to consider in this incident.

It will be interesting to see how this large, first of its kind fine affects the airline industry as a whole.   Statistics show that the new rules have successfully reduced long tarmac delays.  The first year that the rule was in effect, airlines reported only 20 tarmac delays of more than 3 hours, but in the 12 months prior to rule there were 693 delays of more than 3 hours.  But this improvement may come at a high cost.  Especially now that the DOT has shown that they are willing to issue fines, industry analysts are warning that a possible unintended consequence of the new tarmac will be more canceled flights.  The fines are so hefty that airlines may cancel entire flights rather than risk violating the tarmac delay rules, which would obviously have an impact on travelers.  Only time will tell how the new rules will affect airline travel.