July 16, 2009 | Mark Paradies

Root Cause Tip: Root Cause = Sabotage? Can There Be a Case Where There Are No Root Causes Under Management’s Control?

Fire Out at Patrick Cudahy Meat Packing Plant
But Investigation Continues

Here’s the YouTube Video of the start of the fire (from a security camera) …

Analysis shows that a military flare what shot over the building, exploded, and landed on the building. It started a fire that caused $50 million in damage.

The police say there is no indication that the military fired any flare so they are looking at this fire as a crime. (The Wisconsin fire marshal announced a reward of up to $16,000 for information leading to the arrest and conviction of the person or people responsible for the fire.)

Since no security system for a meat packing plant could reasonably be expected to prevent this kind of attack (thus, no chance for a “Human Performance Difficulty” on the Root Cause Tree®), this type of incident would have a “root cause” that gets no further down the tree that the first level. It would stop at “Sabotage”. Thereafter, the investigation becomes a criminal investigations.

From all reports that I’ve read, the firefighting after the fire started was superb. Thus there are no Causal Factors after the Incident on the SnapCharT®.

That makes this a rare case where there wasn’t anything under management’s control that could have stopped this accident.

Here’s more info about the fire from press coverage:

Flare sparked fire at Patrick Cudahy plant – Journal Sentinel, Milwaukee

Patrick Cudahy Plant Fire Out – WISN 12 News

Here’s video (from a distance) of the firefighting efforts …

And another video about the fire…

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