October 24, 2013 | Mark Paradies

Root Cause Analysis Tip: What’s The Incident – What’s the Causal Factor?

CLICK HERE for an article about a fish kill near Honolulu.

It seems that there was a 1,400 ton leak from a molasses pipeline from loading molasses tankers.

The sugary “pollutant” killed thousands of fish.

The dead fish, now being cleaned up by the Hawaii Department of Health, attract sharks, eels, and barracuda (the natural cleanup crew).

Because of the increased risk in shark attacks to surfers, swimmers, and snorkelers, beaches have been posted with an advisory to stay out of the water.

So, up to this point, what is the incident? (The incident in the statement in your circle on your SanpCharT®.)

Leave your answer as a comment here.

But next, if someone ignored the warnings, and entered the water, and was bitten by a shark, would that change the incident? Or would it be a completely separate incident?

Leave your answer in the comments.

Finally, can you already see any causal factors that you should explore as an investigator?

Leave your answer here in the comments.

By the way, is this video a potential corrective action?

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