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.