Cause Mapping Root Cause Analysis - Examples
Each of the following incidents has a web page with a summary Cause Map to review with your group.
Summary List
Wrong Plane
June 2009 -
Unaccompanied Minor - Don't stop at "Procedure not Followed"
On June 14th an unaccompanied minor intending to fly from Boston to Cleveland was inadvertantly seated on a flight to Newark, NJ. This root cause analysis uses a Process Map and a Cause Map to point out both where the breakdowns occurred and why. The Cause Map can reveal specifically where a process failed. A procedure may be accurate, but if it's not followed the work process failed. This same type of "simple mix-up" with medication in a hosptial can result in a fatality. To prevent recurrence all investigation must connect cause-and-effect analysis with work process.
March 2009 -
U.S. Economic Recession 2008-2009 - The "Housing Bubble" Burst
This is a simple root cause analysis for the current U.S. financial mess. It‘s a small piece of a larger root cause analysis we’re continuing to develop. This Financial Mess Cause Map is not yet complete. People have been inundated with a variety of perspectives, each trying to explain "the cause" and who to blame. The financial crisis is an excellent example of a complex problem that is way beyond 5-Whys. Look at the vicious cycles in the Cause Map (feedback loops) that continue to fuel the problem.
February 2009 -
"Cats and Rabbits" - An example of Uninteded Consequences.
Sometimes the solution to a problem can inadvertently create an even bigger problem. The seabird population on Macquarie Island, about half-way between Australia and Antarctica, was being threatened by feral cats. The obvious solution was to remove the cats. With fewer predatory cats, however, the rabbit population exploded. The rabbits consumed an estimated 40% of the island's vegetation creating an ecosystem crisis potentially larger than the original cat problem.
January 2009 -
"Miracle on the Hudson" - A Root Cause "Success" Analysis.
Ordinarily root cause analysis investigations of plane crashes only address the causes of what went wrong, such as the bird strikes, the loss of the engines and ditching in the river. This root cause analysis for US Airways Flight 1549 will also show what went well regarding the smooth ditching, and the successful evacuation and rescue of all onboard. This is an example of a root cause "success" analysis.
July 2000 -
113 Lives Lost - More than a piece of debris.
The loss of the Concorde on July 25, 2000 is a tragic example of how small things can combine in the exact way they needed to, to create a catastrophic incident. All 100 passengers and the 9 crew members as well as 4 people on the ground, were killed when the Concorde crashed into a hotel while attempting to take-off from Charles de Gaulle International Airport outside of Paris, France.
Full-color poster of the Concorde Accident available
for purchase.
September 1999 -
Loss of Mars Satellite - English and metric units confused.
November 1940 -
"Galloping Girdie" - It started with the design.
April 1912 -
"Over 1500 Lives Lost" - There's more to it than the iceberg.