Although they are sometimes treated as a static object, Cause Maps (and any root cause analysis) can – and should – change based on updated or corrected information. A frequent question we get asked is “What if I make a mistake on my Cause Map?” Well, you fix it. Let me show you how.
First, a little background on my error. Last week, I thought it would be important and useful to demonstrate what had happened in the aftermath of Moore, Oklahoma, after a category 5 tornado hit much of the town, including an elementary school. (See the previous blog.) Because there are certain expectations for public safety at an elementary school, I decided to focus the analysis on the children who died at the elementary school and the causes that led to their deaths, as well as information on the potential and implemented solutions to reduce that risk.
I researched how specifically the children had died – an unfortunate necessity to ensure that the solutions are working towards the correct causes – and discovered a statement from the Lt. Gov. of Oklahoma the morning after the tornado saying that the children who died had drowned in the basement due to a burst water main.
As you can imagine, sometimes information that is relayed in the immediate scene of a disaster is not entirely accurate. In this case, the information that the children had drowned was incorrect. Rather, the children who died were in a classroom and died from blunt force trauma and asphyxiation (suffocation) due to being struck or covered by debris from the tornado.
Once we have verified that our initial cause-and-effect relationship is incorrect, we can correct the Cause Map. Rather than just erasing the “wrong” causes and adding in the new causes, we suggest crossing off the causes that have been disproved with evidence. (Click on “Download PDF” above to see an example of a corrected Cause Map.) This way anyone who may have seen an earlier version of the Cause Map, or heard the same initial erroneous information that was used to make it, will have a clear version of what did happen, including the evidence that verifies the correct information.
Obviously the fact that the children died is tragic, so some may wonder what difference it makes exactly how they died. Generally people who are killed in tornadoes are killed by objects striking them. This is why tornado survival drills focus on getting to spots where there is the least possible dangerous debris, or the least risk of the debris becoming dangerous flying objects. Windowless rooms are recommended, because glass can be broken and easily turn into shrapnel. Basements are recommended because the strong winds associated with tornados have less access to underground areas. Bathrooms are another option because most everything in a bathroom is secured to the walls and/or floors. In a pinch, people seek protection under heavy pieces of furniture. (Survivors from the affected school have said that they hid under their desks and held on for dear life.)
Because the basement is a recommended sheltering location, the possibility of drowning from equipment that may be damaged by a tornado meant that the basement needed to be reconsidered as a sheltering location. Because the school did not have a designated safe room, during the 16-minute warning teachers got their students to anywhere they could, including, in many cases, under their own bodies for protection. (Again, based on the extreme damage to the school the death toll, while tragic, demonstrates the remarkably quick and effective action taken the teachers. I can’t emphasize this enough.) Because this protection was very likely causally related to the death toll (in that without the amazing response from the teachers the death toll may have been much higher), I added additional evidence to the cause of injury.
Be aware that changing the causes may impact the recommended solutions. The solutions discussed in the previous blog are still valid, especially the recommendations for inclusion of storm shelters for schools in the area. An additional clarification added in the update is that this has been required since 1999 (after this school was built). All the schools being rebuilt as a result of the tornado damage will have storm shelters, as will schools built in the future. Individual communities will still be faced with the choice of which buildings will and will not be required to have storm shelters, and any incentives that will be put into place to encourage their construction.
To view the Outline and Cause Map, please click “Download PDF” above. Or click here to read more.
