By Kim Smiley
Nobody ever wants to find themselves in the position of dialing 911. But imagine how quickly a bad situation could get even worse if nobody answered your call for emergency help. That is exactly what happened on July 16, 2016 to people in Baltimore, Maryland. For about two hours, people dialing 911 in Baltimore got a busy signal.
This incident can be investigated by building a Cause Map, a visual root cause analysis. A Cause Map intuitively lays out the many causes that contributed to an issue to show all the cause-and-effect relationships. By focusing on the multiple causes, rather than a single root cause analysis, the range of solutions considered is naturally widened.
The first step in the Cause Mapping process is to fill in an Outline with the basic background information for the incident. Additionally, the Outline is used to capture how the incident impacts the overall goals. This incident, like most incidents, impacted more than one goal. For example, the safety goal is impacted because of the delay in emergency help and the customer service goal is impacted because people were unable to reach 911 operators.
The bottom line on the Outline is used to note the frequency of similar incidents. This is important because an incident that has occurred 12 times before may warrant a different level of investigation than an isolated incident. For this example, newspapers reported a previous 911 outage in June in the Baltimore area. The outages appear to have been caused by different issues, but do raise questions about the overall stability of the 911 system in Baltimore. Investigators should determine if the multiple outages are related and indicative of bigger issues than just this one incident.
Once the Outline is completed, the Cause Map itself is built by asking “why” questions. So why was there a 911 outage for about 2 hours? Newspapers have reported that the outage occurred because of electrical power failures after both the main and back-up power systems shut down. The power systems shut down because of a malfunctioning air conditioning unit. No details have been released about exactly why the air conditioning units malfunctioned, but additional information could quickly be added to the Cause Map as it becomes known.
The final step in the Cause Mapping process is to develop and implement solutions to reduce the risk of the problem reoccurring. The investigation into this incident is still ongoing and no information about potential long-term solutions has been announced. In the short term, callers were asked to dial 311 or call their closest fire station or police district station if they heard a busy signal or were otherwise unable to get through to 911. It is probably not a bad idea for all of us to have the numbers of our local fire and police stations on hand, just in case.