Tag Archives: Investigation

Root Cause Analysis - Incident Investigation

Deadly E.Coli Outbreak from Sprouts

By Kim Smiley

Since May, at least 31 people have died and nearly 3,000 have been sickened from E.coli infections in Europe in one of the widest spread and deadliest E.coli outbreaks in recent memory.  After days of confusion, German authorities determined that the source of the contamination is sprouts from an organic farm in northern Germany. The farm has suspended sale of produce and won’t reopen until it is determined safe.

This issue can be investigated by creating a Cause Map, an intuitive format for performing a root cause analysis.  In a Cause Map, the causes contributing to an incident are determined and organized by cause-and-effect relationships.  To view a high level Cause Map of this incident, please click on “Download PDF” above.

This investigation is still underway and additional information can easily be added to the Cause Map as it becomes available. The initial source of contamination at the farm had not yet been determined, but sprouts are known have a high risk of carrying dangerous bacteria.

Sprouts are considered to be a high risk food for a number of reasons.  The seeds are often grown in countries with less stringent inspection criteria so they can arrive at growers already contaminated. Seeds can be contaminated in any number of ways.  E. coli live in the gut of mammals so any time animals or animal waste are near sprout seeds there is a chance of contamination.

It can also be difficult to sanitize the seeds.  Bacteria can hide inside damaged seeds and be missed during sanitizing steps.  Sprouts are also grown in warm water, ideal conditions for growing bacteria as well.  Another factor to consider is that many people eat sprouts raw; cooking would kill any bacteria that were present.

Sprouts have been the source of many bacteria outbreaks in the past.  The U.S. has had at least 30 reported outbreaks related to sprouts in the last 15 years.  Sprouts are associated with enough risk that the Food and Drug Administration has issued warnings for those at high risk, (children, the elderly, pregnant women and people with compromised immune systems) to avoid eating raw sprouts.  If you fall into the high risk category or are just feeling nervous after recent events, the easiest way to prevent bacterial infection from sprouts is to cook them.

Root Cause Analysis - Incident Investigation

Tornado Season of 2011: Worst Ever?

By ThinkReliability Staff

2011 is on pace to be the worst tornado season since record keeping began in 1950.  Communities nationwide have been affected this year, not just those in “Tornado Alley” where twisters are most commonly found.  The marked increase has many wondering just what is going on.  Is it simply greater media attention?  Or perhaps just bad luck this year?  Or maybe this is all because of global warming…

Weather experts agree that it is a combination of factors, but nothing out of the ordinary.  Weather is cyclical, and a higher number of deadly tornados than usual have touched down this year.  Currently 52 deadly tornados have already struck, compared with an annual average of 22.  Additionally these tornados happen to have stuck heavily populated areas.  As recent as April of this year, the EPA has stated that “to date, there is no long-term evidence of systematic changes in [thunderstorms and tornados] over the course of the past 100 years.”

However, some contend that the higher number of tornados must be tied to climate change.  They argue that all the extra energy being stored in the atmosphere is being “expressed in stronger winds…in stronger rainfall.”  How else would it be possible to explain the catastrophic natural phenomenon occurring the last few years?

This is where the Cause Mapping process can help focus all parties on solving the problem, instead of arguing or blaming.  The first step in the process is to define the issue by its impact to overall goals.  In this case, all parties can agree that the destruction and loss of life are the principle impacts.

The next step is to analyze the causes in a visual map.  A simple Cause Map can lay the foundation for a more detailed analysis, so a 5-Why map is usually the best starting point.  From there more causes can be added to the map; all possibilities should be included on the first draft.  When all possible causes are included, it focuses on team on brainstorming instead of debating.

Let’s take a closer look at why so many tornados have hit densely populated areas.  There are primary four reasons identified in the Cause Map.  First, there have been more tornados.  This could be because more are being counted, due to better weather tracking capabilities, or because there simply are more occurring.  Second, there are more forceful tornados than usual.  This could be related to more supercell thunderstorms, since most tornados spring from these types of weather systems.  Because this isn’t known for sure, a question mark indicates that more evidence is needed to support or disprove this hypothesis.  Likewise, it’s possible more strong weather systems are being caused by global warming.

Instead of stopping the analysis to debate global warming, it’s most productive to continue exploring why tornados are touching down in population centers.  It’s not simply a function of the tornados.  There also happen to be more people near where tornados are, and there are more structures which are susceptible to tornado damage.

More people are near where the tornados are because there are more people.  While this is straightforward, it’s often overlooked in the debate and is precisely a reason why more people would perish in a tornado.  People might also be in the area because they have little time to evacuate or take appropriate shelter, unlike in a hurricane.  Advance warning averages just 11 minutes.

Despite many advances in Doppler radar technology and satellite data, tornados are still generally detected the old fashioned way.  Today, a web of 290,000 trained volunteers, called SKYWARN, provide severe weather alert information to the National Weather Service.  Since its inception in the 1970s, SKYWARN has helped the NWS to issue more timely and accurate severe weather warnings.  The NOAA’s National Severe Storms Lab is looking to improve that advanced warning time to 20 minutes, so this might be a possible solution to reducing the number of deaths and injuries caused by tornados.

The fourth factor is that people tend to be located in buildings which are highly susceptible to tornado damage.  More Americans are living in manufactured or modular homes than in previous decades.  As of 2009, there were 8.7 million mobile homes in the United States.  Mobile homes account for nearly half of tornado fatalities.  When other factors are normalized, the data shows unequivocally that mobile homes are more likely to sustain catastrophic damage during tornados.  Some states have begun to take steps to improve the building codes for such dwellings and also to require hardened shelters at mobile home sites.

As even this fairly simple Cause Map demonstrates, there are many factors contributing to this season’s frightening weather.  Focusing on a single cause can mask the many reasons required to produce an effect, and in the end only limits productive debate.

Root Cause Analysis - Incident Investigation

Plane Clips Another While Taxiing at JFK Airport

By Kim Smiley

Around 8:30 pm on April 11, 2011, a large passenger airplane taxiing at John F. Kennedy Airport in New York clipped the wing of a smaller plane.  The larger plane involved in the incident was an Airbus A380 carrying 485 passengers and 25 crew members.  The smaller plane was a Bombardier CRJ and carrying 52 passengers and 4 crew members at the time it was clipped.

At the time of the accident, the Airbus was taxiing to take off and the CRJ had recently landed and was waiting to park.  The incident was caught on amateur video and it appears that the left wing tip of the Airbus struck the left horizontal stabilizer of the CRJ. No injuries were reported, but both planes sustained some damage.

After the planes made contact, the fire department responded as a precautionary measure.  Passengers were deplaned from the Airbus so that the planes could be inspected and information could be gathered to support the investigation.

At this time there is limited information available about what caused this incident, but the National Transportation and Safety Board (NTSB) has begun an investigation.  The NTSB has requested fight recorders from both airplanes and also plans to review the air traffic control tapes and the ground movement radar data to determine how this happened.

Even through the investigation is just getting started, it is still possible to create a Cause Map based on what is known.  The first step is to create an Outline of the event by determining the impact to the organization goals.  In this example, the Safety Goal was impacted because there was the potential for injuries, the Customer Service goal was impacted because the passengers were unable to reach their destination, the Production Schedule Goal was impacted because the flight was unable to depart and the Material and Labor goal was impacted because there was damage to both planes.

From this point, Causes can be added to the cause map by asking “why” question. Missing information can be noted by adding a Cause box with a “?”.  Any additional information can be added later.  To see an initial Cause Map of this incident and the Outline, click on the “Download PDF” above.

Root Cause Analysis - Incident Investigation

Toxic Red Sludge Spill

By Kim Smiley

On Monday, October 4, 2010, a massive wave of red sludge flooded into four villages near Kilontar, Hungary when a storage reservoir burst.  Four were killed and at least 150 have needed medical treatment for their injuries.  The most common injuries reported are burns and eye ailments.

Red sludge is a highly caustic material that is produced during the aluminum manufacturing process.  Reports indicate that the sludge had a pH of 13 while stored in the reservoir.  All life has been killed in a 25 mile stretch of river and 16 square miles of land have been covered by the pollution.  Best estimates are that 158 million to 184 million gallons of sludge were released.  This first large scale release of red sludge in history.

Hungary’s top investigative agency is looking into the accident, but the cause for the reservoir barrier failure is not known at this time.

Even with the unknowns, a root cause analysis can be started by creating a Cause Map and documenting all available information.  Any new information can easily be incorporated into the existing Cause Map.

To build a Cause Map, we start with the impacted goals and ask “why” questions.  In this example, the two goals we will consider are the Safety goal and the Environmental goal.  Starting with the Safety goal we begin by asking – Why were people injured?  They were injured because they were exposed to caustic material because red sludge flooded into their villages.  Why?  Because red sludge was stored in a nearly reservoir and the barrier on the reservoir was breached.

Why the barrier failed isn’t known, but we can still add additional information that might be useful.  We know that the red sludge reservoir was near the villages and a little research reveals that this is common practice in the region and that there are a number of similar pools nearby.  This information may become relevant if the investigation determines that the other reservoirs are at risk for a similar failure so it’s worth recording on our Cause Map at this point. There is also information available about the environmental impact that can be added.

The investigation is still incomplete, but the Cause Map can grow as more information comes available.  Once the relevant information is added, the Cause Map can be used to develop solutions to help prevent similar accidents from occurring in the future.

Root Cause Analysis - Incident Investigation

Known Terror Suspect Boards Plane

By Kim Smiley

On May 1, 2010 authorities found a car bomb in a smoking Nissan Pathfinder in Times Square in New York City (NYC). The bomb had been ignited, but thankfully failed to explode and was disarmed before any damage was done.

The vehicle identification number (VIN) number had been removed from the dashboard and the door sticker, but police retrieved it from the bottom of the engine block.  The VIN was used to identify Faisal Shahzad as the person who recently purchased the car.  The investigation used this evidence in addition to other information to identify Mr. Shahzad as a suspect in the car bomb attempt.  Early in the afternoon of May 3, his name was added to the no-fly list and an email notification was sent to airlines.  In order to view the new name, airlines would have needed to check a website for the most recent no-fly list.

As the investigation continued, Shahzad was put under surveillance, but somehow eluded authorities and drove to JFK airport in NYC undetected.  The evening of May 3, he bought an airline ticket and was able to get through security and board a plane traveling to United Arab Emirates.  He boarded the plane approximately seven hours after his name was added to the no-fly list.

Luckily, investigators learned that Shahzad was on the plane when a final passenger list was sent to officials at the federal Customs and Border Protection agency minutes before takeoff.  He was apprehended before the plane took off and is now in custody.

How was a suspect on the no-fly list allowed to board a plane headed overseas?

A root cause analysis built as a Cause Map can be used to analyze this incident.  This incident is an impact to the Safety goal because a known terror suspect on the no-fly list nearly left the country.  The Cause Map can be built by starting at the impacted goal and asking why questions to add causes.  In this example, the suspect nearly got away because he was allowed to buy a ticket and got through security.  This happened because the airline was using an outdated version of the no-fly list that didn’t include the name because it had recently been added to the list.

There are still a number of causes that are unknown in this case, but an initial Cause map can be viewed by clicking on the “Download PDF” button above.