Causal Factors and remembering one of the worst incidents in American history

We just returned from enjoying our Independence Day Holiday here in the US.

There were many good shows over the weekend about American History and during one I watched I was reminded of one of the worst events in our history (from a workplace safety standpoint); the Triangle Shirtwaist Fire in 1911.

Most safety professionals know of this incident as the Life Safety Code was partially born from the tragedy. I started to think about the incident in terms of TapRooT®, Causal Factors in particular. In our courses, we teach the concept of initiating errors, and chances to stop/catch/mitigate. There were many failures that day and many lost opportunities to stop and mitigate the event.

Possible causal factors that would be identified if TapRooT® would have been used:

CF – fire started (initiating error)

CF – egress blocked/not sufficient for the number of people to escape

CF – exit doors locked

CF – fire escapes collapsed

CF – fire hoses did not work

CF – ladders from fire department did not reach higher floors

I am sure there are more, but these are the ones that jumped out at me while watching the show.

It is a real shame that so many had to die for better conditions to become the norm.

Triangle Shirtwaist Factory fire escape collapsed during the March 15, 1911 fire. 146 died, either from fire, jumping or falling to the pavement.

For more on Causal Factors and stop/catch/mitigate, see this earlier POST