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Root Cause Analysis - Incident Investigation

Department of Energy Cyber Breach Affects Thousands, Costs Millions

By ThinkReliability  Staff

Personally identifiable information (PII), including social security numbers (SSNs) and banking information, for more than 104,000 individuals currently or formerly employed by the Department of Energy (DOE) was accessed by hackers from the Department’s Employee Data Repository database (DOEInfo) through the Department’s Management Information System (MIS).  A review by the DOE’s  Inspector General in a recently released special report analyzes the causes of the breach and provides recommendations for preventing or mitigating future breaches.

The report notes that, “While we did not identify a single point of failure that led to the MIS/DOEInfo breach, the combination of the technical and managerial problems we observed set the stage for individuals with  malicious intent to access the system with what appeared to be relative ease.”  Because of the complex interactions between the systems, personnel interactions and safety precautions (or lack thereof) that led to system access by hackers, a diagram showing the cause-and-effect relationships can be helpful.  Here those relationships – and the impacts it had on the DOE and DOE personnel – are captured within a Cause Map, a form of visual root cause analysis.

In this case, the report uncovered concerns that other systems were at risk for compromise – and that a breach of those systems could impact public health and safety.  The loss of PII for hundreds of thousands of personnel can be considered an impact to the customer service goal.  The event (combined with two other cyber breaches since May 2011), has resulted in a loss of confidence in cyber security at the Department, an impact to the mission goal.  Affected employees were given 4 hours of authorized leave to deal with potential impacts from the breach, impacting both the production and labor goals.  (Labor costs for recovery and lost productivity are estimated to cost $2.1 million.)  The Department has paid for credit monitoring and established a call center for the affected individuals, at an additional cost of $1.6 million, leading to a cost of this event of $3.7 million.  With an average of one cyber breach a year for the past 3 years, the Department could be looking at multi-million dollar annual costs related to cyber breaches.

These impacts to the goals resulted from hackers gaining access to unencrypted PPI.  Hackers were able to gain access to the system, which was encrypted, and contained significant amounts of PPI, as this database was the central repository for current and former employees.  The PPI within the database included SSNs which were used for identifiers, though this is contrary to Federal guidance.  There appeared to have been no effort to remove SSNs as identifiers per a 5-year-old requirement for reasons that are unknown.  Reasons for the system remaining unencrypted appear to have been based on performance concerns, though these were not well documented or understood.

Hackers were able to “access the system with what appeared to be relative ease” because the system had inadequate security controls (only a user name and password were required for access), and could be directly accessed from the internet, presumably in order to accomplish necessary tasks.   In the report, ability to access the system was directly related to “continued operation with known vulnerabilities.”  This concept may be familiar to many at a time when most organizations are trying to do more with less.   Along with a perceived lack of authority to restrict operation, inability to address these vulnerabilities based on unclear responsibility for applying patches, and vulnerabilities that were unknown because of the limited development, testing, troubleshooting and ongoing scanning of the system, cost was also brought up as a potential issue for delay in addressing the vulnerabilities that contributed to the system breach.

According to the report, “The Department should have considered costs associated with mitigating a system breach … We noted the Department procured the updated version in March 2013 for approximately $4,200. That amount coupled with labor costs associated with testing and installing the upgrade were significantly less than the cost to mitigate the affected system, notify affected individuals of the compromise of PII and rebuild the Department’s reputation.”

The updated system referred to  was purchased in March 2013 though the system had not been updated since early 2011 and core support for the application upon which the system was built ended in July 2012.  Additionally, “the vulnerability exploited by the attacker was specifically identified by the vendor in January  2013.”  The update, though purchased in March,  was not installed until after the breach occurred.  Officials  stated that a decision to upgrade the system had not been made until December 2012, because it had not reached the end of its useful life.”  The Inspector General ‘s note about considering costs of mitigating a system breach is poignant, comparing the several thousand dollar cost of an on-time upgrade to a several million dollar cost of mitigating a breach.   However, like the DOE, many companies find themselves in the same situation, cutting costs on prevention and paying exponential higher costs to deal with the inevitable problem that will arise.

To view the Outline, Cause Map and recommended solutions based on the DOE Inspector General’s report, please click “Download PDF” above.  Or click here to read more.

Root Cause Analysis - Incident Investigation

Poisoned Dead Mice Parachuted onto Guam to Kill Snakes

By Kim Smiley

On December 1, 2013, 2,000 dead, poisoned neonatal mice were parachuted onto Guam on a unique mission to fight an invasive species, the brown tree snake. The parachutes are designed to catch in the trees and tempt the snakes, who live in the trees, into eating the mice. The mice are pumped full of acetaminophen, a chemical that the snakes are particularly sensitive to because it affects their blood’s ability to carry oxygen.

There are an estimated 2 million brown tree snakes on Guam so the 2,000 poisoned mice will only impact a very small percentage of the population, but scientists hope that the information they learn from this drop will help them plan larger mice drops in the future.  This is the fourth and largest dead mice drop so far and cost 8 million dollars.  Some of the mice were embedded with data-transmitting radios for this drop which will allow scientists to better gauge the effectiveness of this technique.

While the 8 million dollar price tag sounds high, it’s important to realize that the damage done by the brown tree snakes each year is significant.  Since their accidental introduction to the island, brown tree snakes have destroyed the native ecosystem, decimating the native bird population.  Brown tree snakes are also fantastic climbers and they routinely get into electrical equipment.  They cause an average of 80 power outages a year, resulting in costs as high as $4 million for repairs and lost productivity annually. (See our previous blog for more information.)

Even through the problem of the brown tree snakes is fairly well understood, an effective solution has been difficult to find.  There have been a number of different things tried over the years: snake traps, snake-sniffing dogs and snake-hunting inspectors have all been used, but the snakes have completely over un the island.  As farfetched as it sounds, parachuting dead mice seems to be the most promising solution at present.  It works because the snakes are very sensitive to acetaminophen; they only need to ingest about one-sixth of a standard pill for it to be effective.  This means that non-target animals are unlikely to be heavily impacted by the mice drops.  A pig or dog would need to eat around 500 of the baited mice for the dose to be lethal. One of the concerns is that snakes tend to avoid prey that is already dead, but information from the radio transmitters used in the recent drop should confirm if the mice are an effective bait.

One thing I know for sure, I would have loved to be in the brainstorm meeting the first time someone suggested parachuting dead mice.  This example is a good reminder to all of us to keep an open mind.  Every now and then, the most bizarre solution suggested turns out to be the best.

Root Cause Analysis - Incident Investigation

Can the Epidemic of Smartphone Thefts be Stopped?

By Kim Smiley

About 1.6 million handheld devices were stolen in the United States in 2012, the majority of which were smartphones.  In fact, the frequency at which the popular Apple devices are taken has given rise to a whole new term, “apple picking”.  Stolen smartphones cost consumers nearly $30 billion a year.  These thefts affect a significant number of smartphone owners with approximately 10 percent reporting that they have had a device stolen.

The problem of smartphone theft can be analyzed by building a Cause Map, a method for performing a visual root cause analysis.  A Cause Map is built by completing an Outline by both filling in the basic background information and listing how the issue impacts the overall goals.  The impacts to the goals from the Outline are then used as the first step in building the Cause Map.  Causes are then added by asking “why” questions to determine what other causes contributed to an issue.  (To view a high level Cause Map of this issue, click on “Download PDF” above.)

So why do so many smartphone get taken?  Smartphones are a popular target because it is lucrative to resell them, they are relatively easy to steal, and many of the crimes go unpunished.  Smartphones are fairly easy to steal because they are readily available since so many people carry them, and they are both small and light weight.  Many criminals who steal smartphones go unpunished because there are so many of them taken and it is difficult to locate the thieves.  Many stolen smartphones are shipped overseas which further complicates the situation.

The black market for smartphones is lucrative because the items are popular and relatively expensive to buy new.  People buy stolen smartphones because they are cheaper and they are able to be used by the “new owner”, especially overseas where the networks are different and phones deactivated in the US may be able to be used.

One of the possible solutions suggested to reduce the number of smartphone thefts is to include a kill switch in smartphone software.  This kill switch would essentially make the phone worthless because it would no longer function no matter where it was in the world.  If smartphones no longer have resale value, then there would be little incentive to steal them and the number of thefts should dramatically decrease.  While this idea is elegant in its simplicity, like most things there is more that needs to be considered.

The addition of a kill switch was recently rejected by cellphone carriers because of concerns about hacking and problems with reactivation.  If hackers found a way to flip the kill switches they would have the ability to destroy a huge number of smartphones from anywhere in the world.  Depending on how many users were targeted this could have a huge impact, which could be especially problematic for people who use their phones in an official capacity like law enforcement. It doesn’t take much imagination to see how this scenario could go horribly wrong. The proposed kill switch is also permanent so users won’t be able to reactivate their phones and any stolen phones that were recovered would be useless.  Companies continue to work on a number of ideas to make it more difficult to resell smartphones, but there isn’t general agreement on the best approach yet.  Only time will tell if the tide of smartphone thefts has peaked.

Root Cause Analysis - Incident Investigation

16-Day Government Shutdown Affects Economy

By Holly Maher

On October 1, 2013 at 12:01 AM, the beginning of the 2014 fiscal year, the federal government shut down all non-essential operations when Congress could not pass a continuing resolution to allow spending at current levels. The government shutdown lasted 16 days and, in addition to other impacts, closed the National Parks system (see our blog about the park closures), furloughed 800,000 federal employees, had the potential to impact payment of veterans’ benefits and negatively impacted the economy, both directly and indirectly.

So what caused the government shutdown? If you watched any TV during that 16 day period, you could certainly hear any number of experts (on both sides) explaining who was to blame. As the Cause Mapping methodology is intended to do, this analysis of the government shutdown is not trying to identify the one person, the one group or the one reason to blame for the shutdown. Instead, we will identify all the causes required to produce this effect. This will allow us to identify many possible solutions for preventing it from happening again. We start by asking “why” questions and documenting the answers to visually lay out all the causes that contributed to the shutdown. The cause and effect relationships lay out from left to right.

In this example, the government shutdown occurred because a vote on a continuing resolution bill could not be passed by Congress because there was a line item added to the continuing resolution, defunding the Affordable Care Act (ACA) that could not be agreed upon. A continuing resolution was required because the Constitution gives the power to spend money to Congress, and since they had not passed a Budget for fiscal year 2014, a continuing resolution was constitutionally required to continue operating the government after October 1. Defunding the ACA was added to the continuing resolution bill because the ACA was about to go into effect and because it can be added on a line item basis. Congress was unable to compromise to reach an agreement to pass the continuing resolution.

So why was Congress unable to reach an agreement? If the incentive to compromise was greater than the incentive to not compromise, they would have compromised. So why is the incentive to compromise ineffective? One of the reasons is because Congress’s pay is not affected when the government shuts down. Another reason is because there is significant incentive to maintain a position aligned with the party (either left or right). The desire to get re-elected (which is unlimited within Congress), the need for support in the primaries to get re-elected (based on the current primary system), and the need for campaign financing are all causes that support the incentive to maintain alignment with the party versus compromise.

Once all the causes of the government shutdown have been identified, possible solutions to prevent the shutdown from happening again can be brainstormed. One possible solution would be to legally require a continuing resolution to be a “clean” bill, with no additional line items. This would make it more likely in the future, when there are debates or discussions over current, hot button items, such as the ACA, that the result would not be a failure to pass the continuing resolution and therefore cause a government shutdown. Another possible solution would be to stop pay for Congress during the government shutdown. Other more global, systemic solutions might be to implement term limits in Congress or provide government campaign financing to reduce the dependency on party financial support.

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

Root Cause Analysis - Incident Investigation

“Ghost Train” Causes Head-On Collision in Chicago

By Kim Smiley

On September 30, 2013, an unoccupied train collided head on with another train sending 30 people to the hospital in Chicago.  In a nod to the season and the bizarre circumstances of the accident, the unoccupied train has been colorfully dubbed “the ghost train”. 

So what caused the “ghost train” and how did it end up causing a dangerous train collision?  Investigators from the National Transportation Safety Board (NTSB) are still reviewing the details of the accident, but some information is available.  An initial Cause Map, or visual root cause analysis, can be built to capture what is already known and can be expanded to incorporate more information as the investigation progresses.  A Cause Map is built by asking “why” questions and documenting the answers to visually lay out all the causes that contributed to an accident to show the cause-and-effect relationships from left to right.

In this example, the trains collided because an unoccupied train began moving and the safety systems in place did not stop the train.  Investigators still haven’t determined exactly what caused the train cars to move, but a key piece of the puzzle is that there was still power to the cars while they were being stored in a repair terminal awaiting maintenance.  The NTSB believes that it was common practice to leave power to cars so that the lights could be used to illuminate the terminal.  Workers used the lights to discourage graffiti and vandalism because the terminal was located in a high crime neighborhood. 

Investigators will need to not only determine why the train started rolling, but also learn more about why the safety systems didn’t prevent the accident.  Before colliding with another train, the unoccupied train traveled through five mechanical train-stop mechanisms, each of which should have stopped a train without a driver.  Emergency brakes were applied at each train-stop that caused the train to pause momentarily, but then it started moving because the setting on the master lever caused the train to restart.  Review of the safety systems will need to be part of the investigation to ensure that adequate protection is in place to prevent anything similar from occurring again.

The NTSB investigation is still ongoing, but the NTSB has stated that de-energizing propulsion power and using an alternate brake setting could help prevent unintended movement of unoccupied train cars. Additionally, the NTSB believes the use of a wheel chock and/or derail would ensure that a train stopped by a mechanical train stop mechanism remains stopped.  Based on the information already uncovered, the NTSB has issued an urgent safety recommendation to the Federal Transit Authority (FTA). The NTSB recommended that the FTA issue a safety advisory to all rail transit properties to review procedures for storing unoccupied train cars to ensure that they were left in a safe condition that wouldn’t allow unintended movement and to ensure that they had redundant means of stopping any unintended movement.  There is more information that is needed to fully understand this accident, but these precautions would be effective solutions that can be quickly implemented to reduce the risk of train accidents.

Root Cause Analysis - Incident Investigation

Utah Fights for National Parks

By ThinkReliability Staff

Beginning on October 1, 2013 with the failure to spending approval, the US government entered a partial shutdown including the complete closure of the National Parks, as specified in the National Park Service Contingency Plan.  While the government shutdown had far-reaching effects, both across industry and geographically, areas of Utah   have been hit particularly hard by the closure of multiple National Parks in the area. The shutdown finally ended on October 17 when the government reached a deal to reopen.

A large proportion of Utah businesses are dependent on revenue brought in from tourists visiting the multiple Federal lands in the state, which include National Parks, National Monuments and National Recreation Areas.  A total of five counties in Utah declared a state of emergency, with the counties saying they’re losing up to $300,000 a day.  San Juan County, the last to declare a state of emergency, went a step further and decided it would reopen the parks themselves using local personnel to provide necessary emergency response and facilities for park visitors.

On October 10, the state of Utah came to an agreement with the Department of the Interior to pay for the Park Service to reopen the park for up to 10 days at a cost of $166,572 a day.  (It is possible, though not automatic, that the state will be reimbursed for these costs after funding is restored.)  Luckily a “practical and temporary solution” (as described by the Secretary of the Interior Sally Jewell) was found before county officials had to resort to what they described as “civil disobedience”.  (Trespassing in a National Park can result in a citation that could lead to fines or jail terms.)

This situation mirrors that frequently found on a smaller scale in all workplaces.  Concerned employees find themselves in circumstances that they believe are not in the best interest of their company or customers.  If support for change is not provided by management, these employees will develop work-around (like illegally reopening a National Park to allow tourists to enter).  Sometimes workarounds are actually a more effective way of completing work tasks, but they can also sometimes lead to unintended consequences that can be disastrous.

This is why the most effective work processes are developed with the experience and insight of employees at all levels.  Taking their concerns into account at the development of procedures and on an ongoing basis will reduce the use of potentially risky workarounds, and can increase the success of all an organization’s goals.

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

Root Cause Analysis - Incident Investigation

What Happens When a Copy Isn’t a Copy?

By Kim Smiley

Think of how many documents are scanned every day. Imagine how important some of these pieces of paper are, such as invoices, property records, and medical files. Now try to picture what might happen if the copies of these documents aren’t true copies. This is exactly the scenario that Xerox was recently facing.

It recently came to light that some copies of scanned documents were altered by the scanning process. Specifically, some scanner/copier machines changed numbers on documents. This issue can be analyzed by building a Cause Map, an intuitive, visual format for performing a root cause analysis. The first step in the Cause Mapping process is to fill in an Outline with the basic background information on an issue. Additionally, the impacts to the overall goals are documented on the Outline to help clarify the severity of any given issue. In this example, the customer service goal is impacted because the scanners weren’t operating as expected. There is also a potential impact to the overall economic goal because the altered documents could result in any number of issues. There is also an impact because of the labor needed to investigate and fix the problem.

After completing the Outline, the next step is ask “why” questions to build the Cause Map. Why weren’t the scanners operating as expected? This happened because the scanners were changing some documents during the scanning process. Scanners use software to help interpret the original documents and Xerox has stated that the problem happened because of a software bug. Testing showed that the number substitutions were more likely to occur when the settings on the scanners were set to lower quality/ higher compression because of the specific software used for these settings. Testing also showed that the error was more likely to occur when scanning those documents that were more difficult to read such as those with small fonts or that had already been copied multiple times.

Xerox had been aware of the potential for number substitution at lower quality settings, but didn’t appear to expect it to occur at factory settings (which was found to be very unlikely, but possible). A notice that stated that character substitutions were possible appeared on the scanners when lower resolution settings were selected and was included in some manuals, but this approach seems to have been ineffective since many users were caught unaware by this issue.

After a Cause Map has been built with enough detail to understand the issue, it can be used to help develop solutions. In this example, Xerox developed a software patch that corrected the error. Xerox also posted several blogs on their website to keep customers informed about the issue and worked with users to ensure that the patch was successful in correcting the error.

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

 

Root Cause Analysis - Incident Investigation

Thousands Injured Each Year From Falling Televisions

By Kim Smiley

Nearly all parents know about the dangers of watching too much television, but a new study shows that too few are aware of the risk of injury from televisions.  The number of television injuries is more than most would guess with more than 17,000 children visiting emergency rooms for  television related injuries each year.   Falling televisions have also caused hundreds of deaths with 29 killed in just 2011.  The rate of injuries associated with televisions is also increasing at an alarming pace, jumping 126% since 1990.

The majority of victims were young children under five.  The accidents seem to be a potentially deadly combination of their lack of situational awareness and unanchored televisions set on unsafe surfaces.  The study didn’t include why the televisions were in unsafe locations, but one theory is that many older televisions are moved into secondary locations that aren’t as safe as families acquire bigger, fancier televisions.  The older televisions may be on dressers or night stands that were never meant to hold televisions.  Children climb the furniture either attempting to turn on the television or retrieve something off the top and the television tumbles down on top of them.  Dressers with drawers are particularly dangerous because children may figure out how to use the drawers as steps and manage to climb much higher than anticipated.

The rapid rate of technological advances may also play a role since typical families are buying new televisions more frequently than in previous decades and the number of televisions in an average home has increased.  The changing design of televisions is also relevant.  New thinner televisions have significantly smaller bases making them top heavy and more likely to topple over.  Many families are also buying bigger televisions with can amplify the danger if they topple.

Experts have suggested a few potential solutions to this problem.  First and foremost, parents need to be made more aware of the issue, possibly through a public awareness campaign.  A campaign to distribute anchoring devices has been discussed as well as providing them with new televisions at purchase.  Another option may be to add stability requirements to new designs so that televisions are less likely to topple.  It is also recommended that parents never store remote controls or toys on top of a television because they may entice children into climbing to reach them.  Only time will tell which solution if any are implemented, but this study is a first step in raising public awareness about this issue.

To view a Cause Map, or visual root cause analysis, of this issue, click on “Download PDF” above.  A Cause Map visually lays out the causes that contribute to a problem to show the cause-and-effect relationships and can help clarify a situation.  The possible solutions are included on the Cause Map.

Root Cause Analysis - Incident Investigation

The 8 Worst Typos Ever Made

By ThinkReliability Staff

When we perform a root cause analysis, we occasionally find that something as seemingly minor as a typo has had a huge impact on an organization’s bottom line, their reputation, or even public safety.  The following is a collection of some of the worst typos ever made, with respect to impacts to the organization’s goals.

8. Misspelling your own name 

The Oops: In 2008, a New Hampshire newspaper misspelled its own name, in the front page title, specifically by adding an extra “s”.  Missouri State University misspelled its own name on bags provided to students (Univeristy [sic]).  The error was pointed out by a student.  However, the most well-known of this kind of error probably occurred when “Chile” was misspelled on their 50-peso coin.  The misprinting occurred in 2008, but was not noticed until late 2009.  (Rather than CHILE, the coin said “CHIIE” [sic].  The coins are now collectors’ items.)

The Impact:  The general  manager of the Chilean mint was fired for the coin error.  In the newspaper and university cases, actual cost was minimal and the main impact was abject embarrassment.  However, typos can frequently result in loss of opportunities.  Some recruiters have said that when they get multiple submissions for a single job, resumes with errors go straight to the shredder.

7. Counting on a computer to do your job for you 

The Oops: On January 7, 2009, the US Army admitted that 7,000 letters addressed “Dear John Doe” were sent out to family members of soldiers killed in Iraq.

The Impact: The Army immediately issued a formal apology and sent a personal note to the families.  The letters were sent to the correct families, but there must have been a devastating moment for the families when they thought they may have received someone else’s letter . . . and then realized they hadn’t.

6. Entering the wrong number 

The Oops: On February 5, 2011, an employee at a company in Japan listed 610,000 shares of a job recruiting company at 1 yen apiece.  What it really meant to do was list 1 share at 610,000 yen (~$5,000).  A surprising number of similar stories abound, including a listing on April 5, 2006 for flights from Canada to Cyprus for $39 CAD, instead of $3,900.

The Impact: Although the company in Japan tried to cancel the order, it was processed by the Tokyo Stock Exchange, resulting in a loss of $225 million.   In the case of the surprisingly cheap airline tickets, they were honored by the airline (after initially trying to cancel the tickets) to 500-2000 people, resulting in a very expensive typo indeed.

5. Incorrect punctuation 

The Oops: A communications company in Canada thought it had a five-year deal beginning in spring 2002 with a utility company to add cable lines to thousands of utility poles.  Then the utility company cancelled in early 2006.  The Canadian Radio-television and Telecommunications Commission determined that, because of an extra comma, the contract said that the contract could be cancelled with one-year’s notice, even during the first five years.  (The area in question said the contract: “shall continue in force for a period of five years from the date it is made, and thereafter for successive five year terms, unless and until terminated by one year prior notice in writing  by either party.”)  A missing hyphen in the coded computer instructions was partially responsible for the loss of steering on Mariner 1, which was launched on July 22, 1962.

The Impact: After the cancellation, the utility upped its rates for the use of the poles, which will result in the communications company paying about $2.13 million more than it thought.  But if you think that’s expensive, even worse was the loss of Mariner 1, which had to be blown up when it could no longer be steered.  The value of the Mariner 1 in 1962 was $18.5 million.

4. Using the wrong units 

The Oops: The Mars Climate Orbiter was lost on September 23, 1998 while trying to establish orbit around Mars.  Turns out the trajectory was lower than expected (allowing the orbiter to be subjected to the extreme heat of the Martian atmosphere) because incorrect velocity changes were used in calculations.  Specifically, results from a software program were provided in pound force (English System of Units) and the program predicting the velocity assumed the results were  in Newtons (International System of Units, or SI), a factor of difference of 4.45.  (Read more about the Mars Climate Orbiter.)

The Impact: The Mars Climate Orbiter was destroyed with a complete loss of mission.  The orbiter cost $125 million in 1998.

3. Leaving out a (very important) word 

The Oops:  The interesting thing about some small words (like “not” or “out”) is that they change the meaning of the entire sentence.  A man named Bruce Wayne Morris (who does not become Batman) was sentenced to death in 1987 after the jury was given the choice of death or prison for life with the possibility of parole.  The choice was in fact between execution or a life sentence without parole.

The Impact: Morris’ death sentence was reversed by a federal appeals court in 2001 – that’s right, 11 years later.  (The cost of 11 years worth of deliberation and appeals is not known.)  It is thought that the jury originally opted for the death sentence rather than worrying about him being released on parole at some point in the future.

2. Checking the wrong box 

The Oops:  On January 28, 2013, Evan Spencer Ebel was released from jail, the result of a clerical error.  In 2008, while serving eight years, Ebel pleaded guilty to assaulting a prison guard.  The additional sentence was to be served after the original eight-year sentence.  Instead, the record indicated that the second sentence was to be served concurrent with the original sentence.

The Impact: Ebel is believed to have murdered a pizza delivery man on March 17 and the executive director of the state Department of Corrections on March 19 before he was killed by deputies in Texas on March 21.  A similar situation also ended in tragedy when Charles Anthony Edwards III was mistakenly discharged  in January 2012 from a high-security mental hospital in California, where he is suspected of fatally stabbing a shop owner.

1. Writing illegibly 

The Oops:  While bad penmanship may not necessarily be considered a typo, it can result in the same kinds of problems.  Bad penmanship means that the person who has to read it is much more likely to read it incorrectly.  In one such case, the registration for a ship’s Emergency Position Indicating Radio Beacon (EPIRB) was written sloppily, and a “C” become a “0”.  This didn’t much matter until more than two years later, on March 24, 2009, when the ship (Lady Mary) began to sink and set off its EPIRB.  Because the code was entered incorrectly, it took more than an hour and a half to locate the ship.

The Impact: By the time the Lady Mary was reached (the delay was due to other compounding errors as well), only one crew member was able to be saved.  The other six men were lost at sea.

What to do so this doesn’t happen to you 

When something is important, give it an extra edit.  Specifically, find someone who is not a coworker (a coworker will likely gloss over the same things you did, like the name of your organization).  Motivated teenagers make great editors.  Offer them a dollar for every error they find.  (It’s well worth it.)

Note that legal documents, given the importance of their exact wording and difficulty changing any whoopsies, should be extra, extra carefully edited.

If you really don’t have time to get an independent edit, try reading it out loud.

When your computer is doing some of the work for you, it’s probably a good idea to actually look at a few of the results.

When you’re working with numbers, which are much more difficult to check for errors than words (“univeristy” [sic] is not a word, but 39 is still a number), perform a related math calculation.  One that in particular could have come in handy here is the percentage reduction in the cost of the item.   (Plane tickets at 99% off?  Maybe you want to look at that one again.)

Also, your math teachers weren’t kidding about always using units with your numbers.  Or else you might as well answer the question “How far is it?” with “10”.  If at any point in your analysis a different unit of measurement comes up, go ahead and write both, the way many cookbooks and measuring cups now contain both ounces (English System of Units) and milliliters (Metric System of Units).

All the editing tips above may help, but maybe more important is an understanding of the possible impact of a seemingly innocuous typo.  Yes, they happen to everyone.  But before you let them out of your office, take another look.  If someone thinks you’re wasting your time, show them the two million-dollar examples above.

I’ve made a handy sheet to remind you why you care about editing.  To take a look and print it out for your wall, please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Plan to Control Invasive Snakes with Drop of Dead Mice

By Kim Smiley

Brown tree snakes are an invasive species that was inadvertently introduced to Guam where they have decimated native bird populations and done massive environmental damage.  It’s estimated that there are about two million of these snakes  on the island.  The newest plan of attack in the battle to control the brown tree snake population is to poison the snakes by parachuting dead mice laced with pain killers onto Guam.

The problem of invasive brown tree snakes can be analyzed by building a Cause Map, a visual root cause analysis.  A Cause Map is built by asking “why” questions and adding the causes to intuitively show the cause-and-effect-relationships.  The first step is to identify the goals that are impacted.  In this example, the environmental goal is impacted because the balance of native species on Guam has been altered.  This has happened because the native bird population has been decimated because they have been eaten by an invasive predator, the brown tree snake.  The spider population has also exploded because many of the birds, their main predator, have disappeared.  The snakes also cause significant and expensive power outages on Guam as they climb into electrical equipment.

Brown tree snakes have taken over Guam for several reasons.  First, the snake was accidently introduced to the island, likely as a stowaway in military cargo after World War II.  Once the snake was on the island, it thrived because the species had no major predator on the island, there was little competition for resources, and there was an abundant food source.  There was little competition because Guam had only one other snake species prior to the introduction of the brown tree snake.  The native snake species is blind and significantly smaller, preying mostly on insects.  The brown tree snake had ample food because it is a pretty flexible predator happy to eat birds, lizards, bats and small mammals.  In fact, the brown tree snake has found Guam so hospitable that the snakes grow larger on Guam than in their native habitat where predators are more plentiful and food is more limited.

Presence of these snakes on Guam has caused massive damage.  Nine of twelve native bird species are extinct on the island.  The snakes have also eaten a significantly amount of the small mammal population.  There has also been a huge impact on vegetation on Guam since the snakes have wiped out many of the pollinators.  Scientists have been trying to find ways to improve the situation.

The newest plan involves dropping dead mice laced with pain killers onto Guam.  The pain killers are deadly to the snakes if ingested.  The mice will be attached to something called a flagger, which is two pieces of cardboard attached with a streamer.  The flagger should act like a parachute and catch in the tree canopy, which is where the snakes predominately spend their time.  The hope is that the snakes will then eat the pain killer laced mice, thus reducing their population.  The current plan is to drop about 2,000 mice over an enclosed area to determine if this is an effective method of brown tree snake population control.  If it works, more dead mice could be headed Guam’s way in the future.

To view a Cause Map of the brown tree snake problem and a Process Map of the plan to drop dead mice, click on “Download PDF” above.  To view a similar example about controlling feral cats on Macquarie Island, click here.