Tag Archives: public health

Root Cause Analysis - Incident Investigation

911 Outage in Baltimore

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.

Root Cause Analysis - Incident Investigation

Heavy metal detected in moss in Portland

By Kim Smiley

Residents and officials are struggling to find a path forward after toxic heavy metals were unexpectedly found in samples of moss in Portland, Oregon. According to the U.S. Forest Service, the moss was sampled as part of an exploratory study to measure air pollution in Portland.  The objective of the study was to determine if moss could be used as a “bio-indicator” of hydrocarbons and heavy metals in air in an urban environment.  Researchers were caught off guard when the samples showed hot spots of relatively high heavy metal levels, including chromium, arsenic, and cadmium (which can cause cancer and kidney malfunction).  Portland officials and residents are working to determine the full extent of the problem and how it should be addressed.

So where did the heavy metals come from?  And how is it that officials weren’t already aware of the potential issue of heavy metals in the environment? The investigation into this issue is still ongoing, but an initial Cause Map can be built to document what is known at this time.  A Cause Map is built by asking “why” questions and visually laying out all the causes that contributed to the problem.  (Click on “Download the PDF” to view the initial Cause Map.)

Officials are still working to verify where the heavy metals are coming from, but early speculation is that nearby stained-glass manufacturers are the likely source.  Heavy metals are used during the glass manufacturing process to create colors. For example, cadmium is used to make red, yellow and orange glass and chromium is used to make green and blue glass. The hot spots where heavy metals were detected surround two stained-glass manufacturers, but there are other industrial facilities nearby that may have played a role as well.  There are still a lot of unknowns about the actual emissions emitted from the glass factories because no testing has been done up to this point.  Testing was not required by federal regulations because of the relatively small size of the factories.  If the heavy metals did in fact originate from the glass factories, many hard questions about the adequacy of current emissions regulations and testing requirements will need to be answered.

Part of the difficulty of this issue is understanding exactly what the impacts from the potential exposure to heavy metals might be.  Since the levels of heavy metals detected so far are considered below the threshold of “acute”,  investigators are still working to determine what the potential long-term health impacts might be.

A long-term benefit of this mess is the validation that moss can be used as an indicator of urban air quality.  Moss has been used as an “bio-indicator” for air quality since the 1960s in rural environments, but this the first attempt to sample moss to learn about air quality in an urban setting.  As moss is plentiful and testing it is relatively inexpensive, this technique may dramatically improve testing methods used in urban environments.

Both glass companies have voluntarily suspended working with chromium, cadmium and arsenic in response to a request by the Oregon Department of Environmental Quality.  The DEQ has also begun additional air monitoring and begun sampling soil in the impacted areas to determine the scope of the contamination. As officials gain a better understanding of what is causing the issue and what the long-term impacts are, they will be able to develop solutions to reduce the risk of similar problems occurring in the future.

Root Cause Analysis - Incident Investigation

Neurotoxin makes California crabs unsafe to eat

By Kim Smiley

California officials have delayed indefinitely both recreational and commercial fishing for Dungeness and Rock crab from the coast north of Santa Barbara all the way to the Oregon border because the crabs have been determined to be a threat to public safety.  Testing has shown that many of the crabs in this region contain potentially unsafe levels of domoic acid, a powerful neurotoxin, that can cause illness in humans if they consume the crabs. Domoic acid poisoning causes vomiting, diarrhea, cramping and can even lead to brain damage and death in severe cases.  Scientists are continuing to test crabs caught off the California coast and the hope is to open crabbing season if/when the crabs are found to be safe for consumption.

A Cause Map, a visual root cause analysis, can be built to help understand the causes that contribute to this issue.  The first step in building a Cause Map is to understand the impacts from the issue being considered.  Obviously this issue has the potential to impact public safety because the crabs have the potential to cause illness, although no cases of domoic acid poisoning in humans have been reported in this year. The economic impact to the fishing industry from the delay in the start of crabbing season is also very significant.  California’s crabbers typically gross about $60 million a year and many families depend on the money made during crab season to live on throughout the year.  This issue also impacts the environment because humans aren’t the only animals that can suffer from domoic acid poisoning and other creatures are continuing to eat the contaminated crabs.  Sea lions in particular have been affected by the neurotoxin and many have died.  Removing large predators has the potential to significantly impact the entire ecosystem.

The Cause Map itself is built by asking “why” questions and laying out the answers to intuitively show the cause-and-effect relationships. So why do the crabs have high levels of domoic acid in their bodies?  This year off the coast of California, warmer than typical ocean temperatures have led to an unusually large and long-lasting algae bloom created by Pseudo-nitzschia. Domoic acid is naturally produced by Pseudo-nitzschia and it can be concentrated into dangerous levels as it moves up the food chain.  Small fish and shellfish such as krill, anchovies and sardines consume the domoic acid along with the algae.  Crabs eat the smaller creatures that have been contaminated with domoic acid.  Crabs can eventually excrete the domoic acid, but the process is slow and takes enough time that the domoic acid can build up to high levels in the bodies of the crabs.  If bigger creatures such as humans and sea lions eat the contaminated crabs, they can be poisoned by the domoic acid that was initially produced by the algal bloom.  There is nothing that can make the contaminated crabs safe for consumption. Neither cooking nor cleaning can eliminate the risk of poisoning from the neurotoxin so the only safe option is to wait until the domoic acid returns to safe levels in the crabs.

To view an Outline that lists the impacted goals and see a high level Cause Map of this issue, click on “Download PDF” above.

Root Cause Analysis - Incident Investigation

Volkswagen admits to use of a ‘defeat device’

By Kim Smiley

The automotive industry was recently rocked by Volkswagen’s acknowledgement that the company knowingly cheated on emissions testing of several models of 4-cylinder diesel cars starting in 2009.  The diesel cars in question include software “defeat devices” that turn on full emissions control only during emissions testing.  Full emissions control is not activated during normal driving conditions and the cars have been shown to emit as much as 40 times the allowable pollution.   Customers are understandably outraged, especially since many of them purchased a “clean diesel” car in an effort to be greener.

The investigation into this issue is ongoing and many details aren’t known yet, but an initial Cause Map, a visual format for performing a root cause analysis, can be created to document and analyze what is known.  The first step in the Cause Mapping process is to fill in a Problem Outline with the basic background information and how the issue impacts the overall organizational goals.  The “defeat device” issue is a complex problem and impacts many different organizational goals.  The increased emissions obviously impacts the environmental goal and the potential health impacts of those emissions is an impact to the safety goal.  Some of the specific details are still unknown, like the exact amount of the fines the company will face, but we can safely assume the company will be paying significant fines (on the order of billions) as a result of this blatant violation of the law.  The Volkswagen stock price also took a major hit and dropped more than 20 percent following the announcement of the diesel emissions issues.  It is difficult to quantify how much the loss of consumer confidence will impact the company long-term, but being perceived as a dishonest company by many will certainly impact their sales.   A large recall that will be both time-consuming and costly is also in Volkswagen’s future.  Depending on the investigation findings, there is also the potential for criminal prosecution because of the intentional nature of this issue.

Once the overall impacts to the goals are defined, the actual Cause Map can be built by asking “why” questions.  So why did these cars include “defeat devices” to cheat on emissions tests?  The simple answer is increased profits.  Designing cars that appeared to have much lower emissions than they did in reality allowed Volkswagen to market a car that was more desirable. Car design has always included a trade-off between emissions and performance.  Detailed information hasn’t been released yet, but it is likely that the car had improved fuel economy and improved driving performance during normal driving conditions when full emissions control wasn’t activated. Whoever was involved in the design of the “defeat device” also likely assumed the deception would never be discovered, which raises concern about how emissions testing is performed.

The design of the “defeat device” is believed to work by taking advantage of unique conditions that exist during emissions testing. During normal driving, the steering column moves as the driver steers the car, but during emissions testing the wheels rotate, but the steering column doesn’t move.  The “defeat device” software appears to have monitored the steering column and wheels to sense when the conditions indicated an emissions test was occurring.  When the wheels turned without corresponding steering wheel motion, the software turned the catalytic scrubber up to full power, reducing emissions and allowing the car to pass emissions tests. Details on how the “defeat device” was developed and approved for inclusion in the design haven’t been released, but hopefully the investigation into this issue will be insightful and help understand exactly how something this over the line occurred.

Only time will tell exactly how this issue impacts the overall health of the Volkswagen company, but the short-term effects are likely to be severe.  This issue may also have long-reaching impacts on the diesel market as consumer confidence in the technology is shaken.

To view an Outline and initial Cause Map of this issue, click on “Download PDF” above.

Root Cause Analysis - Incident Investigation

Legionnaires’ Disease Outbreak Blamed on Contaminated Cooling Towers

By ThinkReliability Staff

An outbreak of Legionnaires’ disease has affected at least 115 and killed 12 in the South Bronx area of New York City. While Legionnaires’, a respiratory disease caused by breathing in vaporized Legionella bacteria, has struck the New York City area before, the magnitude of the current outbreak is catching the area by surprise. (Because the vaporization is required, drinking water is safe, as is home air conditioning.) It’s also galvanizing a call for actions to better regulate the causes of the outbreak.

It’s important when dealing with an outbreak that affects public health to fully analyze an issue to determine all the causes that contributed to the problem. In the case of the current Legionnaires’ outbreak, our analysis will be performed in the form of a Cause Map, or visual root cause analysis. We begin by capturing the basic information (what, when and where) about the issue in a problem outline. Because the issue unfolded over months, we will reference the timeline (to view the analysis including the timeline, click on “Download PDF”) to describe when the incident occurred. Some important differences to note – people with underlying medical conditions and smokers are at a higher risk from Legionnaires’, and Legionella bacteria are resistant to chlorine. Infection results from breathing in contaminated mist, which has been determined to have come from South Bronx area cooling towers (which is part of the air conditioning and heating systems of some large buildings).

Next we capture the impact to the goals. The safety goal is impacted due to the 12 deaths, and 115 who have been infected. The customer service goal is impacted by the outbreak of Legionnaires’. The environmental and property goals are impacted because at least eleven cooling towers in the area have been found to be contaminated with Legionella. The issue is resulting in increased regulation, an impact to the regulatory goal, and testing and disinfection, which is being performed by at least 350 workers and is an impact to the labor goal.

The analysis begins by asking “why” questions from one of the impacted goals. In this case, the deaths resulted from an outbreak of Legionnaires’ disease. The outbreak results from exposure to mist from one of the contaminated cooling towers. The design of some cooling towers allows exposure to the mist produced. It is common for water sources to contain Legionella (which again, is resistant to chlorine) but certain conditions allow the bacteria to “take root”: the damp warm environment found in cooling towers and insufficient cleaning/ disinfection. The cost of cleaning is believed to be an issue – studies have found that, like this outbreak, impoverished areas are more prone to these types of outbreaks. Additionally, there are insufficient regulations regarding cooling towers. The city does not regularly inspect cooling towers. According to the mayor and the city’s deputy commissioner for disease control, there just hasn’t been enough evidence to indicate that cooling towers are a potential source of Legionnaires’ outbreaks.

Evidence would indicate otherwise, however. A study that researched risk factors for Legionnaires’ in New York City from 2002-2011 specifically indicated that proximity to cooling towers was an environmental risk. A 2010 hearing on indoor air quality discussed Legionella after a failed resolution in 2000 to reduce outbreaks at area hospitals. New York City is no stranger to Legionnaires’; the first outbreak occurred in 1977, just after Legionnaires’ was identified. There have been two previous outbreaks of Legionnaires’ this year. Had there been a look at other outbreaks, such as the 2012 outbreak in Quebec City, cooling towers would have been identified as a definite risk factor.

For now, though the outbreak appears to be waning (no new cases have been reported since August 3), the city is playing catch-up. Though they are requiring all cooling towers to be disinfected by August 20 and plan increase inspections, right now there isn’t even a list of all the cooling towers in the city. Echoing the frustrations of many, Bill Pearson, member of the committee that wrote standards to address the risk of legionella in cooling towers, says “Hindsight is 20-20, but it’s not a new disease. And it’s not like we haven’t known about the risk of cooling towers, and it’s not like people in New York haven’t died of Legionnaires’ before.”

Ruben Diaz Jr., Bronx borough president, brings up a good point for the cities that may have Legionella risks from cooling towers, “Why, instead of doing a good job responding, don’t we do a good job proactively inspecting?” Let’s hope this outbreak will be a call for others to learn from these tragic deaths, and take a proactive approach to protecting their citizens from Legionnaire’s disease.

Root Cause Analysis - Incident Investigation

Can a “Super Banana” Reduce Vitamin A Deficiency?

By Kim Smiley

Vitamin A deficiency is rare in developed countries, but it remains a major public health issue in more than half of all countries, particularly in especially in Africa and South-East Asia. Researchers at the Queensland University have created a “super banana” genetically engineered to contain alpha- and beta-carotene that they hope will reduce vitamin A deficiency in parts of the world where bananas are a staple crop.

The problem of vitamin A deficiency can be analyzed using a Cause Map, a visual format for performing a root cause analysis. A Cause Map is built by determining how an issue impacts the overall goals and then asking “why” questions and laying out the answers visually to show the cause-and-effect relationships. In this example, the overall goal of public safety is impacted because vitamin A deficiency causes 650,000 – 700,000 deaths and results in blindness in 250,000-500,000 children annually. This occurs because the body, especially growing bodies, needs vitamin A to function properly and the diet does not contain adequate vitamin A.

Bodies use vitamin A in a number of ways. For example, vitamin A is important for healthy vision and a lack of it will result in blindness.  It has been shown to play an important role in the immune system. Diets in some regions of the world lack enough vitamin A because they are poor subsistence-farming communities that predominantly consume locally grown crops and the local crops don’t contain sufficient vitamin A.

There have been a number of different ways to help reduce the occurrence of vitamin deficiency such as distribution of vitamins and introduction of new crops, but the problem of vitamin deficiency is still a widespread issue which led to the idea of genetically modifying local crops to be more nutritious. The idea behind the “super banana” is that they would look the same as other East African Highland bananas and grow in the same conditions, but that they would be enriched with additional nutrients. The inside of the “super bananas” is more orange than regular East African Highland bananas, but the outside looks the same.

Lab tests with gerbils have been successful and the first human trials of the modified bananas are scheduled starting this summer. If the human trials are successful, the next necessary step is for Uganda’s legislature to approve a bill allowing the crops to be grown. Researchers are hoping to have the modified bananas growing in Uganda by 2020 if the government approves the project.

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