Tag Archives: Solutions

Root Cause Analysis - Incident Investigation

Two Firefighters Killed by Rogue Welding

By ThinkReliability  Staff

On March 26, 2014, two firefighters were killed when trapped in a basement by a quickly spreading, very dangerous fire in Boston, Massachusetts. These firefighters appear to have been the first to succumb to injuries directly caused by fire while on the job in 2014. The company that was found responsible for starting the fire has been fined by OSHA for failure to follow safety procedures. Says Brenda Gordon, Occupational Safety and Health Administration (OSHA)’s director for Boston and southeastern Massachusetts, “This company’s failure to implement these required, common-sense safeguards put its own employees at risk and resulted in a needless, tragic fire.”

Every incident that results in a fatality should be carefully investigated. Investigations are used not only for liability and regulatory reasons, but also to develop solutions to reduce the risk of similar fatalities happening in the future. Investigating an incident such as this in a Cause Map, or visual root cause analysis, allows for better solutions by determining all the cause-and-effect relationships that led to the issue.

First it’s important to define how goals were impacted in order to define the scope of the problem. In this case, two firefighters were killed, which impacts the safety goal. In addition, the spread of the fire, damage of nearby buildings and associated civil lawsuits are also impacts to the goals. The OSHA fine of $58,000 for 10 violations of workplace safety regulations is an impact to the regulatory goal. The response to the fire, as well as the multiple investigations, are impacts to the labor/time goal.

Beginning with an impacted goal and asking “Why” questions develops cause-and-effect relationships that explain how the incident occurred. In this case, the firefighters perished when they were trapped by fire. The firefighters were in the basement of a residential building to rescue occupants from a fire, and the fire was so hot and dangerous that the firefighters could not exit, and other firefighters were unable to come to their rescue. Extremely windy conditions spread the fire caused by a welding spark that struck a nearby wood shed.   OSHA investigators note that the company performing the welding did not follow safety precautions (including having a fire watcher and moving welding away from flammable objects) that would have reduced the risk for fire. They cited the lack of an effective fire prevention/ protection program and a lack of training in workplace and fire safety. View the Cause Map by clicking “Download PDF” above.

Ideally the fine levied by OSHA will encourage the company involved to increase its methods of fire protection, not only to protect its own workers, but also to protect the public. In addition, the Boston Fire Department is conducting an internal review to improve firefighter safety. Says Steve MacDonald, spokesman, “What they’re doing is looking at policies and procedures. They’re reviewing everything, reviewing weather, radio communications, anything and everything having to do with the fire.”

On July 5th, another firefighter died after being trapped in a building while looking for occupants during a fire in Brooklyn, New York. On July 9th, a firefighter in Houston, Texas was killed of smoke inhalation inside a burning building. A firefighter died in a building collapse due to fire in New Carlisle, Indiana on August 5, 2014, making a total of 5 firefighters who have died as a direct result of smoke/fire injuries while on the call of duty so far in 2014. In 2013, a total of 30 firefighters were killed on the job, most as the result of the Yarnell Hill fire in Arizona.

Root Cause Analysis - Incident Investigation

Children Served Bleach from Reused Milk Jug

By ThinkReliability Staff

For morning snack on September 11, 2014, a substitute teacher’s aide was getting ready to pour water for snack on her first day on the job. Unfortunately, what she poured from a reused plastic milk container was actually a beach solution used for cleaning. The mistake was realized quickly, but not before 28 children and 2 adults ingested some of the bleach. Luckily the concentration was low enough that there were no injuries, although all who ingested the solution were seen at a local hospital.

The substitute teacher’s aide was fired and the school reopened the next day, though the New Jersey Department of Children and Families will be investigating. Clearly serving cleaning solution to children under your care is undesirable. However, firing the person most directly involved without fixing any of the issues that contributed to the mistake may leave an unacceptable risk for the issue to happen again. Although this appeared to be the first time anything like this happened on such a scale in a day care facility, the misuse of cleaning fluid due to confusing containers has happened before. Just this July a woman was given an epidural of cleaning fluid after containers were accidentally switched. (See our blog to learn more.)

Identifying the impacted goals and all the causes that led to those impacted goals allows for more solutions than just firing the person found to be most immediately responsible. The use of a Cause Map, a visual form of root cause analysis, diagrams all the cause-and-effect relationships in order to develop as many solutions as possible so the most effective among them can be implemented.

First the impacts to the goals are identified. The safety goal is impacted because of the potential for injury to the 28 children and 2 adults who drank the bleach solution. The bleach solution was stored in a food container, which can be considered an impact to the environmental goal. The customer service goal is impacted because the children and adults were served bleach solution. The day care worker being fired, and the ongoing investigation by the licensing agency, can both be considered impacts to the regulatory goal. Additionally, the treatment of all 30 who ingested the solution impacts the labor goal.

Beginning with one impacted goal, we ask “why” questions to determine cause-and-effect relationships. In this case, the safety goal impact of potential injury is due to the children and teachers drinking the bleach solution they were served. The bleach solution was served by the fired employee who was apparently unaware that the milk jug actually stored bleach solution. The executive director indicated that the jug was labeled, so this is apparently not an uncommon practice at the site. The question this raises is, why was an old milk jug used to store cleaning solution?

The American Association of Poison Control Centers (AAPCC) says: “DO NOT use food containers such as cups or bottles to store household and chemical products” and “Store food and household chemical products in separate areas. Mistaking one for the other could cause a serious poisoning.” Although the reused container was apparently labeled (though not clearly enough to avoid the mistake), it should never have been reused in the first place. As indicated by the AAPCC, reusing containers between food and cleaning supplies is just too big of a risk. It’s also worth noting that reusing a bottle that contained household chemicals for a different household chemical is another no-no: “Never mix household chemical products together. Mixing chemicals could cause a poisonous gas.” Don’t run the risk at your workplace or home. Don’t reuse food containers for cleaning products or mix cleaning products.   Fortunately the children at this day care center got off without lasting damage in this case.

Root Cause Analysis - Incident Investigation

App Takes Down National Weather Service Website

By Kim Smiley

The National Weather Service (NWS) website was down for hours on August 25, 2014.  Emergency weather alerts such as tornado warnings were still disseminated through other channels, but this issue raises questions about the robustness of a vital website.

This issue can be analyzed by building a Cause Map, a visual format for performing a root cause analysis.  Cause Maps are built by laying out all the causes that contributed to a problem to show the cause-and-effect relationships.  The idea is to identify all the causes (plural), not just THE one root cause.

This example is a good illustration of the potential danger of focusing on a single root cause.  The NWS website outage was caused by an abusive Android app that bogged the site down with excessive traffic.  The app was designed to provide current weather information and it pulled data directly from the forecast.weather.gov website.  The app inadvertently queried the website thousands of times a second because of a programming error and the website was essentially overwhelmed.  It was similar to the denial of service attacks that have been directed at websites such as Bank of America and Citigroup, but the spike in traffic in this case wasn’t deliberate.

It may be tempting to say that the app was the root cause. Or you could be more specific and say the programming error was the root cause.  But labeling either of these “the root cause” would imply that you solved the problem once you fix the software error. The root cause is gone, no more problem…right?  In order to address the issue, NWS installed a filter to block the excessive queries and worked with app developer to ensure the error was fixed, but there are other factors that must be considered to effectively reduce the risk of a similar problem recurring.

One of the things that must be considered in this example is why a filter that blocked denial of service attacks wasn’t already in place.  Flooding a website with excessive traffic is a well-known strategy of hackers.  If an app could accidently take the site down for hours, it is worrisome to consider what somebody with malicious intent could do.  The NWS is responsible for disseminating important safety information to the public and needs a reasonably robust website.  In order to reduce the impact of a similar issue in the future, the NWS needs to evaluate the protections they have in place for their website and see if any other safeguards should be implemented beyond the filter that addressed this specific issue.

If the investigation was focused too narrowly on a single root cause, the entire discussion of cyber security could be missed.  Building a Cause Map of many causes ensures that a wider variety of solutions are considered and that can lead to more effective risk prevention.

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

Root Cause Analysis - Incident Investigation

Software Glitch Delays U.S. Travel Documents

By Kim Smiley

The Consular Consolidated Database (CCD) is the global database used by the U.S. State Department to process visas and other travel documents.  On July 20, 2014, the CCD experienced software issues and had to be taken offline.  The outage lasted several days with the CCD being returned to service with limited capacity on July 23.  The CCD is huge, one of the largest Oracle-based warehouses in the world, and is used to process a hefty number of visas each year and the effects of the software glitch have been felt worldwide.  The State Department processed over 9 million immigrant and non-immigrant visas overseas in 2013 so a delay of even a few days means a significant backlog.

This issue can be analyzed by building a Cause Map, a visual root cause analysis.  A Cause Map visually lays out the different causes that contribute to an issue so that the problem is better understood and a wider range of solutions can be considered.  The first step in the Cause Mapping process is to define the problem, which includes documenting the overall impacts to the goal.  Most problems impact more than one goal and this example is no exception.

The customer service goal is clearly impacted because thousands – and potentially even millions – have had their travel document processing delayed.  The negative publicity can also be considered an impact to the customer service goal because this software glitch isn’t doing the international image of the U.S. any favors.  The delay in travel document services is an impact to the production/schedule goal and the recovery effort and investigation into the problems impact the labor/time goal.  Additionally, there are potential economic impacts to both individuals who may have had to change travel plans and to the U.S. economy because these issues may discourage international tourism.

The next step in the Cause Mapping method is to build the Cause Map.  This is done by asking “why” questions and using the answer to visually lay out the cause-and-effect relationships.  The delay in processing travel documents occurred because the CCD is needed to process them and the CCD had to be taken offline as a result of software issues.  Why were there issues with the database? Maintenance was done on the CCD on July 20 and the performance issues began shortly thereafter.  The maintenance was done to improve system performance and to fix previous intermittent performance issues. The State Department has stated that this was not a terrorist act or anything more malicious than a software glitch.  An investigation is currently underway to determine exactly what caused the software glitch, but the details have not been released at this time.  It can be assumed that the test program for the software was inadequate since the glitch wasn’t identified prior to implementation.

The final step in the Cause Mapping process is to identify solutions that can be implemented to reduce the risk of a problem recurring.  Details of exactly what was done to deal with the issue in the short term and bring the CCD back online aren’t available, but the State Department has stated that additional servers were added to increase capacity and improve response time.  There is also a plan to improve the CCD in the longer term by upgrading to a newer version of the Oracle database software by the end of the year which will hopefully prove more stable.

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

Root Cause Analysis - Incident Investigation

The Controversy Over the 2010 World Cup Ball

By Kim Smiley

Unlike other sports where the balls remain relatively constant, a new soccer ball is typically unveiled for the World Cup every 4 years.  The changes made to the balls aren’t just cosmetic; the behavior of the soccer ball can vary between designs.  One of the most controversial designs in recent memory was the Janulani, the official ball of the 2010 World Cup that was widely criticized and dubbed “the beach ball”.

The issues surrounding the Janulani soccer ball can be analyzed by building a Cause Map, a visual root cause analysis.  To build a Cause Map, “why” questions are asked to determine what factors contributed to an issue and answers are visually laid out to show the cause-and-effect relationships. To view a Cause Map of this issue, click on “Download PDF”.

So why was the 2010 World Cup ball the focus of so many complaints? Players felt that the ball was unpredictable and behaved differently than previous ball designs.  Scientists studied the Janulani ball and determined that it was less aerodynamically stable, particularly at the speeds typical for a professional free kick, which made the goalie’s job significantly harder and tempers flare.  The Janulani ball was a fundamentally different design: it had fewer panels (8 instead of the traditional 32), a smoother surface and internal stitches.  The ball was basically so smooth it changed how air flowed around it, including the speed where the transition between smooth and turbulent flow occurred.  The placement of the seams was also significantly different and not as balanced so that the ball moved erratically at times.  One can assume that the testing program for the new soccer ball design was inadequate since the changes in flight path patterns were not intentional, so that is another cause that needs to be considered.

It’s also worth noting that the fact that a new soccer ball design was used for the 2010 World Cup is a cause of the problem.  Few other sports have equipment that is changed so frequently and/or debut new equipment at major international events. So why is there a new ball for every World Cup?  Money certainly plays a role since there is a huge demand for World Cup merchandise and a new ball means a new product to sell.  The restrictions governing soccer ball design are also vague – for example, the number of panels are not specified – which allows plenty of wiggle room for innovation.

The problems with the 2010 World Cup ball seem to have been fixed and the 2014 World Cup ball, the Brazuca, doesn’t seem to be generating close to the amount of negative press.  In order to smooth out the flight pattern, this design is about a half-ounce heavier, has a slightly rougher surface and deeper seams.  There has been some speculation that the fast flying Brazuca is responsible for the high number of goals scored this World Cup, but the ball appears to fly predictably – if fast. If you want a stylish new Brazuca official match ball of your own, they are selling for $160 each.

If you are still feeling blue that the US is out the World Cup, try searching #ThingsTimHowardCouldSave.  It should cheer you up a bit.

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.

Root Cause Analysis - Incident Investigation

Fingertips Amputated After Slip on Ice

By ThinkReliability Staff

Information on a slip that caused severe damage to an electrical contractor in Newcastle in August 2013 was recently released by Great Britain’s Health and Safety Executive (HSE). Though this incident didn’t make the front pages of the newspaper, it is representative of many of the injury investigations which we facilitate using the Cause Mapping method.

The first step in the Cause Mapping method of root cause analysis is to capture the what, when and where of the incident and the impacts to the organizational goals. In this case, the what (contractor slip and hand injury), when (August 30, 2013) and where (a moving conveyor at a baguette manufacturer in Leeds) are captured, as well as any differences and the task being performed at the time of the incident. There were two notable differences during the incident as compared to an “average” day that should also be noted: the safety guard had been removed from the conveyor and ice had accumulated on the floor. These differences may or may not be causally related to the incident. Additionally, the task being performed (cleaning up after contract electrical work) is captured as it, too, may be causally related to the incident.

The impacts to the goals are analogous to what stood in the way of a perfect day. A serious injury involving the partial amputation of two fingers and the injury of a third is an impact to the safety goal in this example. The £8,500 fine levied by the HSE is an impact to the regulatory goal. The worker had four weeks off work due to the injury, which is an impact to the labor goal. It is unclear if any other goals were impacted by this incident.

Once at least one impact to the goals has been determined, asking “why” questions helps us complete the second step, or analysis. In the analysis, we capture cause-and-effect relationships that map out the issues that led to the incident. In this case, the injury was caused by the contractor’s hand striking an unprotected drive chain on a moving conveyor. This occurred because the hand struck the area, the drive chain was unprotected, and the conveyor was moving. All three of these causes had to occur for the resulting injury.

The contractor’s hand struck the area because of a slip on an icy floor. Ice from an open freezer door (which appeared to be malfunctioning) had built up and had not been removed.   The drive chain was unprotected because the safety guard had been removed from the conveyor, which was moving likely due to normal operations.

According to Shuna Rank, the HSE inspector, “This worker’s injuries should not and need not have happened. This incident was easily preventable had Country Style Foods Ltd ensured safety guards were in place on the machinery. The company should also have taken steps to prevent the accumulation of ice on the freezer floor. Guards and safety systems are there for a reason, and companies have a legal duty of care to ensure they are properly fitted and working effectively at all times. Slips and trips are the biggest cause of major injuries in the food and drink industry with 37% of all major accidents in the industry being as a result of slips.”

The inspector’s quote clearly identifies the areas for improvement that could reduce the risk of similar incidents occurring. Namely, the manufacturer must ensure that damage resulting in ice buildup is fixed as soon as possible and that in the meantime, ice is regularly cleared away and the area is marked as a slip hazard. If a safety guard is removed for any reason, the conveyor should not be operating until it has been replaced properly. Ensuring that equipment is in proper working order is essential to reduce the risk to workers such as the injuries demonstrated in this case.

To view the Outline and Cause Map, please click “Download PDF” above. Or click here to read more.

Root Cause Analysis - Incident Investigation

Microsoft Withdrawing Support for Windows XP, Still Used by 95% of World’s 2.2 Million ATMs

By ThinkReliability Staff

On April 8, 2014, Microsoft will withdraw support for its XP operating system.  While this isn’t new news (Microsoft made the announcement in 2007), it’s quickly becoming an issue for the world’s automated teller machines (ATMs).  Of the 2.2 million ATMs in the world, 95% run Windows XP.  Of these, only about a third will be upgraded by the April 8th deadline.

These banks then face a choice: upgrade to a newer operating system (which will have to be done eventually anyway), pay for extended support, or go it alone.  We can look at the potential consequences for each decision – and the reasons behind the choices – in a Cause Map, a visual form of root cause analysis.

First we look at the consequences, or the impacts to the goals.  The customer service goal is impacted by the potential exposure to security threats.  (According to Microsoft, it’s more than just potential.  Says Timothy Rains, Microsoft’s Director of trustworthy computing, “The probability of attackers using security updates for Windows 7, Windows 8, Windows Vista to attack Windows XP is about 100 per cent.”)  Required upgrades, estimated to cost each bank in the United Kingdom $100M (US) by security experts, impact the production/schedule and property/equipment goals.   Lastly, if implemented, extended service/ support contracts will impact the labor/time goal.  Though many banks have announced they will extend their contract, the costs of such an extension are unclear, and likely vary due to particular circumstances.

As mentioned above, banks have a choice.  They can upgrade immediately, as will be required at some point anyways.  However, it’s estimated that most (about two-thirds) of banks worldwide won’t make the deadline.  They will then continue to operate in XP, with or without an extended service/ support contract.

Operating without an extended contract will create a high vulnerability to security risks – hackers and viruses.  It has been surmised that hackers will take security upgrades developed for other operating systems and reverse engineer them to find weaknesses in XP.  The downside of the extended contracts is the cost.

Given the risk of security issues with maintaining XP as an operating system, why haven’t more banks upgraded in the 7 years since Microsoft announced it would be withdrawing support?  There are multiple reasons.  First, because of the huge number of banks that still need to upgrade, experts available to assist with the upgrade are limited.  Many banks use proprietary software based on the operating system, so it’s not just the operating system that would need to be upgraded – so would many additional programs.

The many changes that banks have been dealing with as a result of the financial crisis may have also contributed to the delay.  (For more on the financial crisis, see our example page.)  Banks are having trouble implementing the many changes within the time periods specified.  Another potential cause is that banks may be trying to perform many upgrades together.  For example, some ATMs will move to a new operating system and begin accepting chip cards as part of the same upgrade.  (For more about the move towards chip cards, see our previous blog.)

Some banks are just concerned about such a substantial change.  “I ask these companies why they are using old software, they say ‘Come on, it works and we don’t want to touch that,'” says Jaime Blasco, a malware researcher for AlienVault.  The problem is, soon it won’t be working.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause Analysis - Incident Investigation

1 Dead and 27 Hospitalized from Carbon Monoxide at Restaurant

By Holly Maher

On Saturday evening, February 22, 2014, 1 person died and 27 others were hospitalized due to carbon monoxide poisoning.  The individuals were exposed to high levels of carbon monoxide that had built up in the basement of a restaurant.  The restaurant was evacuated and subsequently closed until the location could be deemed safe and the water heater, located in the basement, was inspected and cleared for safe operation.

So what caused the fatality and 27 hospitalizations?  We start by asking “why” questions and documenting the answers to visually lay out all the causes that contributed to the incident.  The cause and effect relationships lay out from left to right.

In this example, the 1 fatality and 27 hospitalizations occurred because of an exposure to high levels of carbon monoxide gas, which is poisonous.  The exposure to high levels of carbon monoxide gas was caused not only by the high levels of carbon monoxide gas being present, but also because the restaurant employees and emergency responders were unaware of the high levels of carbon monoxide gas.

Let’s first ask why there were high levels of carbon monoxide present.  This was due to carbon monoxide gas being released into the basement of the restaurant. The carbon monoxide gas was released into the basement because there was carbon monoxide in the water heater flue gas and because the flue gas pipe, intended to direct the flue gas to the outside atmosphere, was damaged.  The carbon monoxide was present in the flue gas because of incomplete combustion in the water heater.  At this point in the investigation, we don’t have any further information.  This can be indicated as a follow-up point on the cause map using a question mark.  We have also identified the reason for the flue gas pipe damage as a question mark, as we do not currently have the exact failure mechanism (physical damage, corrosion, etc.) for the flue gas pipe.  What we can identify as one of the causes of the flue gas pipe failure is an ineffective inspection process.  How do we know the inspection process was ineffective?  Because we didn’t catch the failure before it happened, which is the whole point of requiring periodic inspections.  This water heater had passed its annual inspection in March of 2013 and was due again in March 2014.

If we now ask the question, why were the employees unaware of the high levels of carbon monoxide present, we can identify that not only is carbon monoxide colorless and odorless, but also there was no carbon monoxide detector present in the restaurant.  There was no carbon monoxide detector installed because it is not legally required by state or local codes.  The regulations only require carbon monoxide detectors to be installed in residences or businesses where people sleep, i.e. hotels.

Once all the causes of the fatality and hospitalizations have been identified, possible solutions to prevent the incident from happening again can be brainstormed.  Although we still have open questions in this investigation, we can already see some possible ways to mitigate this risk going forward.  One possible solution would be to legally require carbon monoxide detectors in restaurants.  This would have alerted both employees and responders of the hazard present.  Another possible solution would be to require more frequent inspections of this type of combustion equipment.

To view the Outline and Cause Map, please click “Download PDF” above.

 

Root Cause Analysis - Incident Investigation

Freight Train Carrying Crude Oil Explodes After Colliding With Another

By Kim Smiley

On Monday, December 30, 2013, a 106-car freight train carrying crude oil derailed in North Dakota and violently exploded after colliding with another derailed train that was on the tracks.  No injuries were reported, but the accident did cause an impressive plume of hazardous smoke and major damage to two freight trains.

The investigation into the accident is ongoing and it’s still unknown what caused the first train to derail. Investigators have stated that it appears that there was nothing wrong with the railroad track or with the signals.  It is known that a westbound freight train carrying grain derailed about 2:20 pm.  A portion of this train jumped onto the track in front of the eastbound train.  There wasn’t enough time for the mile long train loaded with crude oil to stop and it smashed into the grain train, causing the eastbound oil train to derail.  (To see a Cause Map of this accident, click on “Download PDF” above.)

Train cars carrying crude oil were damaged and oil leaked out during the accident.  The train accident created near ideal conditions for an explosion: sparks and a large quantity of flammable fluid.   The fire burned for more than 24 hours, resulting in a voluntary evacuation of nearby Casselton, North Dakota due to concerns over air quality.  The track was closed for several days while the initial investigation was performed and the track was cleaned up.

The accident has raised several important issues.  The safety of the train cars used to transport oil has been questioned.  Starting in 2009, tank train cars have been built to tougher safety standards, but most tank cars in use are older designs that haven’t been retrofitted to meet the more stringent standards.  This accident, and others that have involved the older design tank cars in recent year, have experts asking hard questions about their safety and whether they should still be in use.

The age of the train cars is particularly concerning since the amount of oil being transported by rail has significantly expanded in result years.  Around 9,500 carloads of oil were reportedly transported in 2008 and nearly 300,000 carloads were moved during the first three quarters of 2013.  The oil industry in North Dakota has rapidly expanded in recent years as new technology makes oil extraction in the area profitable.   North Dakota is now second only to Texas in oil production since the development of the Bakken shale formation.  Pretty much the only way to transport the crude oil extracted in North Dakota is via rail.  There isn’t a pipeline infrastructure or other alternative available.

And most of the time, transporting oil via freight train is a safe evolution.  The Association of American Railroads has reported that 99.99 percent of all hazardous materials shipped by rail reach the destination safely.  But it’s that 0.01 percent that can get you in trouble.  As a nation, we have to decide if where we are at is good enough or if it’s worth the money to require all tank cars used to transport oil to be retrofitted to meet the newest safety standards, a proposition that isn’t cheap.