Tag Archives: fire

Root Cause Analysis

Smoke from wildfires in West may impact public health across the US

By ThinkReliability Staff

A significant portion of the United States is currently being affected by wildfires. The Valley and Butte fires in California, two of the worst in that state’s history, have killed five (all civilians found dead in their homes). The Tassajara Fire has resulted in another civilian fatality. The Rough Fire (also in California) has burned more than 141,000 acres. The US Wildfire Activity Public Information Map and National Wildlife Coordinating Group Incident Information System shows dozens more fires across the Western United States.

The wildfires are also impacting the population in areas not directly impacted by the fires. Public safety has been impacted by the deaths and risk for injury. Worker safety has been impacted as well; four firefighters were burned in the Valley fire. Even animal safety has been impacted; animals were left to fend for themselves in many areas that were evacuated rapidly due to changing conditions, leading to risk of injury or death. Tens of thousands of people have been evacuated. Hundreds of thousands of acres have been burned and thousands of buildings destroyed, causing a potential long-term impact on area businesses. More than 15,000 workers have been deployed to assist in fighting the fires.

The wildfires are also affecting air quality in areas not directly impacted by the fires. The smoke from these wildfires is causing environmental and health issues including asthma, chronic lung disease and even heart attacks. Janice Nolan, the assistant vice president for national policy at the American Lung Association says of recent air quality, “It’s really bad. I hadn’t seen ‘code maroon’ days, which is the most hazardous air quality, in years.” (The Air Quality Index reports the quality of outdoor air in color categories. Maroon, or “hazardous” represents a level of air pollution that means the entire population is likely to experience serious health effects. Lower categories indicate when members of more sensitive groups may experience health concerns.)

Health issues can occur when smoke is breathed in and enters the respiratory system. The organic particles that make up smoke can be so small they can bypass the body’s natural defenses (such as mucus and hair in the nose). The particles can even enter the bloodstream. This occurs any time a person is exposed to smoke. Says Sylvia Vanderspek, the chief air quality planner for the California Air Resources Board, “If you can smell smoke, then basically you’re breathing it.”

An average person can breathe in about 35 micrograms of particulate matter for only 24 hours before experiencing health problems. Unfortunately, the California air quality board has measured levels of particulate matter up to 34 micrograms in a day . . . and the fires have been burning for weeks and may continue for weeks more. Weather conditions impact not only the wildfires themselves but also where the smoke from those fires goes. Weather conditions this summer have meant that smoke issues have been seen into the Midwest.

The only really effective protection against health impacts from smoke is to stay inside with air conditioning on recirculate if in an affected area (based on the local air quality index). This has meant schools are holding indoor recess and sports practices and outdoor festivals have had to cancel performances. Idaho is considering establishing clean air shelters so the population can avoid breathing in smoke. Regrettably, most air masks won’t help, as they don’t protect against the tiny particles of concern. Instead, health officials reiterate that if the air quality in your area is poor, stay indoors to protect your health.

Root Cause

11 Patients Killed in Nursing Home Fire

by ThinkReliability Staff

A fire broke out in the early morning hours of November 18, 2011 at a residential aged care facility in Sydney, Australia.  At least 11 residents died as a direct result of the fire and nearly 100 were evacuated.    A nurse was been charged with 11 counts of murder as the fire is believed to be a result of arson. The nurse pleaded guilty to all 11 counts on May 27, 2013. (There have been other resident deaths but due to their age and health, it wasn’t clear if the deaths were a direct result of the fire.)

The cause of the fire initiation resulting in the deaths of residents, evacuation and severe damage to the nursing home facility is believed to have been arson.   The reasons for the arson are unclear and may never be fully understood.  However, there is still value in analyzing the event to determine if there are any other solutions that could reduce the risk of patient death in the future, at this facility or at others.

We can perform a root cause analysis in the highly visual, intuitive form of Cause Mapping to understand the issues that led to the tragedy.  We begin the analysis with the “What, When and Where” of the event, captured in a problem outline.  Additionally, we capture the impacts to an organization’s goals.   In this case, the patient safety goal was impacted due to the deaths.  There was an impact to employees, as a nurse at the facility has pleaded guiltily to murder.  Patient services were impacted due to the evacuation of the nearly 100 residents at the facility. The severe damage to the site resulted in the construction of a new facility, which cost $25 million.  (The cost of the new facility cannot all be attributed to the fire, as the new facility is much larger and has been modernized.)  Last but not least, the labor goal was impacted due to the incredibly heroic rescue efforts by the staff, firefighters and other rescue personnel, who were honored for their efforts.

Capturing the  frequency of similar issues can help provide perspective on  the magnitude of nation and world-wide issues.  I was unable to find data on the prevalence of nursing home fires in Australia, but there are more than 2,000 nursing home structure fires in the United States every year.  There have been a number of fatal nursing home fires in Australia over the last several years, so this is obviously a concern for the nation.

Once we have determined the impacts to the goals, we can ask “Why” questions to determine the causes that resulted in those impacts.  In this case, the resident deaths were due to smoke inhalation and complications from smoke inhalation as the result of a fire that spread through the facility.  The fire initiation, as discussed above, is believed to be due to arson.  However, it is believed that staffing levels and lack of an automatic sprinkler system were related to the spread of the fire, speed of the evacuation and the number of deaths.

Studies after the event showed how critical sprinklers can be to slow the spread of a fire.  On January 1, 2013, the government of New South Wales passed a law requiring installation of automatic sprinkler systems in all residential aged care facilities prior to January 1, 2016.  It is hoped that the presence of an automated sprinkler would slow or prevent the spread of a fire, resulting in fewer resident deaths.

To view the root cause analysis investigation of the fatal fire, please click “Download PDF” above.