Cause Mapping Examples
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Cause Mapping case studies
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The following case studies demonstrate how Cause Mapping can be used to document problems and identify solutions in various industries. Select an industry on the left to view its case studies on the right.

Aviation
Business
Environmental
Food Safety
Health and Nutrition
Industrial
Legal
Marine
Space
Structures

Attempted Bombing of Flight 253– Explosives allowed on a flight to Detroit

At ThinkReliability, we live by the philosophy that the only reason to dispute causes is lack of evidence. But when it comes to some historical concepts, we understand that we may not have that evidence immediately at hand. For example, finding the defining moment when terrorism began or pinpointing why it ever started in the first place would take a rather impressive Cause Map…
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Wrong Plane (Unaccompanied Minor Flown to Wrong City) – Don’t stop at “Procedure Not Followed”

Over the course of two days, a U.S. airline placed an unaccompanied minor on the wrong flight on two different occasions. On June 13th, a child flying alone and under the supervision of the airline was scheduled to fly from Houston to Charlotte. Instead, she ended up in Fayetteville. One day later, a second occurrence with the same airline, this time out of Boston. Instead of going to Cleveland, this unaccompanied girl ended up in Newark, NJ…
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US Airways Flight 1549 (Miracle on the Hudson) – A root cause “success” analysis

Root cause analysis is an approach for identifying the underlying causes of why an incident occurred. The investigation of US Airways Flight 1549 will include both why the aircraft ditched in the river and why all onboard survived. 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…
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Lexington Plane Crash – Attempted take-off on the wrong runway

On the morning of August 27, 2006, a Comair flight scheduled to travel to Atlanta International Airport attempted to take off from the wrong runway. The runway used was too short and the flight crashed near the end of the runway. There 49 people were killed and the single survivor was seriously injured. The plane was destroyed by impact forces and fire…
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Concorde Accident – A failure causes a plane to crash

On the morning of July 25th, 2000, passengers boarded Air France Flight 4590 from Paris to New York and settled in for what was supposed to be a long flight on a supersonic aircraft. Sadly, their flight lasted less than two minutes. Just after liftoff, the supersonic jet crashed into a hotel in Gonesse, France, killing all 109 people aboard and an additional 4 people on the ground. Five minutes before Flight 4590 took to the runway, a Continental flight headed to Newark, using the same runway, lost a titanium alloy strip…
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TWA Flight 800– Mid-air breakup kills 230

On July 17, 1996, TWA Flight 800 broke up in air offshore at East Moriches, New York. All 230 people on board were killed and the plane was completely destroyed. Let’s examine the Cause Mapping process for the in-air break-up of TWA flight 800…
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de Havilland Comet Accidents – Problems with the “most exhaustively tested airplane in history”

Sir Geoffrey de Havilland built the first commercial jet that reached production, the Comet. The Comet design was finalized in 1945, as the British aircraft industry was attempting to establish a commercial aircraft industry post-World War II. Prior to 1954, there had been some problems (a collision at take-off and a mid-air breakup) and some fixes to the hydraulic control system. Then, on January 10, 1954 a Comet broke up in mid-air…
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Hindenburg Explosion– An example of debated causes

This is an example of how the Cause Mapping process can be applied to a specific incident. In this case the Hindenburg crash is captured as an example of the Cause Mapping method. The three steps are 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions…
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Financial Mess - The 'Housing Bubble' burst and more

In December 2008, the National Bureau of Economic Research announced the United States had been in a recession for twelve months. Preliminary reports indicate that in fourth quarter 2008 alone, the United States GDP declined at an annual rate of 6.3%, the worst decline since 1982.
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Hurricane Katrina - 80% of New Orleans flooded, 1100+ deaths

This is an example of how the Cause Mapping process can be applied to a specific incident. In this case the devastation in New Orleans due to Hurricane Katrina is captured as an example of the Cause Mapping method. The three steps in the Cause Mapping method are 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions…
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Yarnell Hill Fire - 19 Firefighter fatalities

This is an example of how the Cause Mapping process can be applied to a specific incident. In this case the Yarnell Hill Fire is captured as an example of the Cause Mapping method. The three steps are 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions…
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Deepwater Horizon Oil Spill - Oil Spill lasts for months as solution after solution fails

The Deepwater Horizon oil rig was in the final stages of exploratory drilling at the Macondo well in the Gulf of Mexico when disaster struck. On April 20, 2010, the rig exploded, killing 11 workers and forcing the evacuation of the rig. It quickly became clear that the emergency measures taken prior to evacuation had not sealed the well and that great amounts of oil were leaking into the Gulf of Mexico…
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Cats & Rabbits on Macquarie Island - An example of unintended consequences

Remember that song about the old lady who swallowed a fly (perhaps she’ll die), and then swallowed a spider to catch the fly, then swallowed a bird to catch the spider? By the end of the song, she’d swallowed a whole horse (she died, of course) trying to solve a problem that had been created while trying to solve another problem. This cautionary tale of unintended consequences has followed us since childhood. Though it is exaggerated (and therefore funny–but really, how does one swallow a horse?), its lesson is more pertinent than one might think: be wary of the war of escalation that may arise when you solve problems without considering the consequences of your solutions…
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Fire - Decoding the fire triangle and fire tetrahedron

146 workers were killed when a fire raced through the Triangle Company, which occupied the top three floors of a skyscraper in New York City. The workers were unable to escape the fire. We can examine this incident using a Cause Map, a visual form of root cause analysis, which allows us to diagram the cause-and-effect relationships that led to organizational issues – in this case, the death of 146 workers…
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Buffalo Creek Flood of 1972 - Dam failure causes massive damage and 125 deaths

This is an example of how the Cause Mapping process can be applied to a specific incident. In this case the Buffalo Creek Flood of 1972 is captured as an example of the Cause Mapping method. The three steps are 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions…
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Pet Food Contamination - Unsafe substitution of products

We spend several billion dollars more on dog and cat food than on baby food. According to Bob Vetere, the president of the American Pet Products Manufacturers Association, 42 percent of pets sleep in the same bed as their owners – up from 34 percent in 1998.

These statistics are startling to some and unsurprising to others. So you can imagine the uproar, panic, fear and anger it might cause when pets are endangered. And you can imagine how pet owners must respond when their own pets are endangered…
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Guinea Worm Disease - Working to eradicate a painful parasite

The lifecycle of the Guinea worm is the stuff of nightmares. This parasite is ingested by a host as larvae, mate and mature inside the host and then the adult female painfully emerges to lay her eggs. The adult female is between two to three feet long and the thickness of a spaghetti noodle. The only way to get rid of the parasite is to wrap it around a stick and slowly pull it out, a process that takes several weeks or even months…
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Hot Coffee (The Spilled McDonald's Coffee) - Debate to the solutions, not the cause

When a 79-year-old woman spilled a cup of McDonald’s coffee in her lap and sued McDonald’s, the case quickly became famous. More than 15 years later, this case is still presented by some as a case for legal reform to stop frivolous lawsuits and defended by others as an important victory for victims of powerful corporations. But regardless of the legal implications, this famous case teaches a lesson about how to effectively solve problems…
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Smoking - Why do people start? Why don't they quit?

Most people who use them wish they could stop, nobody needs them, and nonetheless smokers will purchase their cigarettes with a loyalty and regularity that most other brands could only dream of cultivating in their customer base. According to the CDC, smoking causes an estimated 443,000 premature deaths and costs the United States nearly $200 billion dollars (divided roughly evenly between lost labor costs and health care expenditures) per year; another 8.6 million live with a serious illness caused by smoking. Put differently, one of five Americans per year die completely preventable deaths, 49,000 of which result from secondhand smoke exposure. Such statistics by far exceed what one might consider to be an acceptable level of risk for a completely optional and expendable activity…
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Fukushima Daiichi- Natural disasters damage nuclear power plant

There are many complex events occurring with some of Japan’s nuclear power plants as a result of the earthquake and tsunami on March 11, 2011. Although the issues are still very much ongoing, it is possible to begin a root cause analysis of the events and issues. In order to clearly show one issue, our analysis within this blog is limited to the issues affecting Fukushima Daiichi Unit 3…
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Deepwater Horizon Oil Spill - Oil spill lasts for months as solution after solution fails

The Deepwater Horizon oil rig was in the final stages of exploratory drilling at the Macondo well in the Gulf of Mexico when disaster struck. On April 20, 2010, the rig exploded, killing 11 workers and forcing the evacuation of the rig. It quickly became clear that the emergency measures taken prior to evacuation had not sealed the well and that great amounts of oil were leaking into the Gulf of Mexico…
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Dust Explosions - A root cause analysis primer

How do you actually go about performing a root cause analysis? In the following case, I’m going to follow a speech given by the U.S. Chemical Safety Board Investigations Manager Stephen Selk, P.E. and do a root cause analysis based on it. This speech is for the purpose of updating the public on the investigation of the Imperial Sugar Company explosion and fire in Savannah, Georgia on February 17, 2008 at 1 p.m…
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Explosion at Point Comfort Formosa Facility - Vehicle accident results in large propylene release

This is an example of how the Cause Mapping process can be applied to a specific incident. In this case the explosion at the Formosa facility in Point Comfort, Texas is captured as an example of the Cause Mapping method. The three steps are 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions…
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Davis Besse Reactor Corrosion - Potential breach of containment

On March 5th, a hole with a surface area of 20-30 square inches (about the size of a football) was found in the reactor pressure vessel head (the shell that holds coolant layer around reactor core) of Davis Besse Nuclear Plant. That thin stainless steel covering was the only thing standing in the way of the collapse of the containment structure and widespread radioactive contamination, posing a health risk to thousands in the vicinity and contaminating Lake Erie as well. That might not seem catastrophically dramatic, unless you know that roughly 20% of the drinking water in the United States comes from Lake Erie…
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Three Mile Island - Partial meltdown of the core

The partial meltdown of a core at the nuclear power plant at Three Mile Island is one of the most well known engineering disasters in US history. Luckily, no one was injured and there was no significant environmental impact, but the potential for major issues was very real. Three Mile Island also had a huge impact on the nuclear industry and required a major clean up effort. Performing a root cause analysis of historical incidents is useful because there are a number of lessons learned that can often be applied across a variety of industries.
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Buffalo Creek Flood of 1972 - Dam failure causes massive damage and 125 deaths

This is an example of how the Cause Mapping process can be applied to a specific incident. In this case the Buffalo Creek Flood of 1972 is captured as an example of the Cause Mapping method. The three steps are 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions…
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Buncfield Storage Depot Explosion - 43 injured after tank overfilled

This is an example of how the Cause Mapping process can be applied to a specific incident. In this case the explosion at the Buncefield Storage Depot is captured as an example of the Cause Mapping method. There are three steps to the Cause Mapping process: 1) Define the problem, 2) Conduct the analysis, and 3) Identify the best solutions…
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Triangle Shirtwaist Fire - 46 workers killed in fire

146 workers were killed when a fire raced through the Triangle Company, which occupied the top three floors of a skyscraper in New York City. The workers were unable to escape the fire.
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Wrong Plane (Unaccompanied Minor Flown to Wrong City) - Don't stop at 'Procedures Not Followed'

Over the course of two days, a U.S. airline placed an unaccompanied minor on the wrong flight on two different occasions. On June 13th, a child flying alone and under the supervision of the airline was scheduled to fly from Houston to Charlotte. Instead, she ended up in Fayetteville. One day later, a second occurrence with the same airline, this time out of Boston. Instead of going to Cleveland, this unaccompanied girl ended up in Newark, NJ. This root cause analysis focuses on the failures that occurred within the work processes and emphasizes the use of process maps to help identify where the breakdowns occurred and how to identify specific solutions to prevent re-occurrence…
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Hot Coffee The Spilled McDonald's Coffee - Debate the solutions, not the cause

When a 79-year-old woman spilled a cup of McDonald’s coffee in her lap and sued McDonald’s, the case quickly became famous. More than 15 years later, this case is still presented by some as a case for legal reform to stop frivolous lawsuits and defended by others as an important victory for victims of powerful corporations. But regardless of the legal implications, this famous case teaches a lesson about how to effectively solve problems…
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Loss of the KURSK - A submarine and all crew members are lost

On August 12, 2000, a torpedo exploded on KURSK, leading to the eventual loss of the submarine and all on board. We can demonstrate the causes of the KURSK tragedy by performing a visual root cause analysis, or Cause Map. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page. First we define the problem(s). Here, the problems include a torpedo explosion and submarine sinking. This is the “what”…
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Valdez Oil Spill - Oil tanker strikes reef

Shortly after midnight on March 24, 1989, the VALDEZ, transporting crude oil from Alaska to California, struck Bligh Reef. The damage to the vessel allowed 258,000 barrels (10.8 million gallons) of crude oil to be released into Prince William Sound, in the most ecologically damaging oil spill in North America, and possibly the world…
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Loss of the Titanic - There's more to it than the iceberg

This is an example of how Cause Mapping root cause analysis can be applied to the sinking of the Titanic. Each of the Cause Mapping steps are explained below:

1) Define the problem

2) Analyze the causes

3) Select the best solutions…
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Hubble Focusing Issues - Focus on solutions, not 'the' problem

The images provided by the Hubble telescope have been a stunning achievement for the scientific community. However, the Hubble project was not without its share of problems. The development of the telescope took over a decade and billions of dollars and it was almost lost due to a tiny flaw in the main mirror…
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Loss of Columbia on Re-Entry - Foam strike leads to loss of crew

Loss of the Mars Orbiter - English and Metric units confused

NASA operates on a scale that is largely incomprehensible to those who did not pay extra good attention in their science and math classes. The space program involves complex astrophysics and a highly specialized language full of words like ‘redshifts’ and ‘dark matter,’ words that take on an almost mythical aspect to those who are not versed in the language of space. Its engineering projects are large–space ship large–and necessitate coordination between multiple agencies, providers, machinists, and scientists to realize…
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Challenger Explosion - O-ring leaks in cold weather

The Challenger space shuttle made history repeatedly. Its virgin flight in April of 1983 witnessed the first spacewalk during a space shuttle mission. Two months later, Sally Ride became the first American woman into space aboard the vessel; throughout its subsequent missions, the Challenger also carried the first African-American, Canadian, and Dutchman into space…
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Fire Aboard Apollo 1 - Fire during launch pad testing kills 3 astronauts

It was supposed to be NASA’s first manned Apollo mission to Earth orbit, but it was over before it ever got off the ground. Scheduled to blast off in late February, 1967, the Apollo Command/Service Module was larger and more complex than any spacecraft had ever been. Astronauts Gus Grissom, Edward White, and Roger Chaffee had trained extensively for their mission, and the spacecraft was given a passing grade in August of 1966…
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I-35 Bridge Collapse - Undersized gusset fails after 40 years

The I-35 Bridge stands out in this group for the tremendous damage it caused. It was the most expensive of the three collapses. More importantly, it was the only one of the three that was fatal. The bridge also had poor past assessments from US regulatory agencies, raising questions surrounding state upkeep and maintenance procedures.A hindsight view of the collapse offers new knowledge of how we should maintain bridges. Our Cause Map, built through our own unique, rigorous method of Root Cause Analysis, aims to provide all important information and assess potential solutions by determining the acceptable level of risk…
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Hyatt Regency Walkway Collapse - Inadequate structural design

Assumptions are a double-edged sword; they allow us to function in the modern world, but at times they reveal themselves to be vacuous, and disaster results. This is a familiar theme in Root Cause Analysis. The consequences of assuming, for example, that all members of a large project are working with the same units can come with a billion dollar price tag (as was the case with the loss of the Mars Climate Orbiter. Other times, people pay with their lives…"
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Cook County Administration Building Fire - Botched evacuation kills 6

At approximately 5:00 p.m. on October 17, 2003, a fire began in a storage closet on the 12th floor of a Cook County Administration Building in Chicago. Since there were no Fire Safety Director personnel at the building, the building engineer decided to evacuate. The Emergency Voice/Alarm Communications (EVAC) system was activated, informing personnel that they should evacuate the building using any set of stairs…
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New London School Explosion - Hundreds killed when natural gas explosion levels school

On March 18, 1937, the London School of New London, Texas was leveled by a huge explosion. Unfortunately, many people were in the school on the afternoon of the explosion and an estimated 280 students, 15 teachers, 2 visitors and a school secretary were killed. This tragedy remains the worst catastrophe to occur inside a school in American history…
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1942 Fire at the Cocoanut Grove Nightclub - Nightclub fire kills 492

This is an example of how the Cause Mapping process can be applied to a specific incident. In this case the 1942 fire at the Cocoanut Grove Nightclub is captured as an example of the Cause Mapping method. The three steps are 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions. Each step will be discussed below…
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Tacoma Narrows Bridge (Galloping Gertie) - The collapse started in the design phase

The original Tacoma Narrows Bridge was opened for traffic on July 1, 1940. The suspension bridge spanned over a mile and had a unique, slender design. The bridge quickly became nick named “Galloping Gertie” because it experienced large up and down movement on windy days. On the morning of November 7 1940, the movement of the Tacoma Narrows bridge changed from the usual longitudinal motion to a never before seen twisting mode. The peak twisting motion of the roadbed is estimated to have been 25 ft from crest to valley…
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