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February 8, 2016 | Ken Reed

Meteorite Casualty: Natural Disaster in TapRooT® Root Cause Analysis

meteor

Photo of meteor from Chelyabinsk, Russia in 2013

If confirmed, here is a link to the first recorded fatality due to a meteorite strike in modern history. This would be one of the few appropriate uses of the Natural Disaster category on the Root Cause Tree®.

When doing a root cause analysis using TapRooT®, one of the top-level paths you can follow can lead you to Natural Disaster as a possibility. We note that this doesn’t come up very often. When you go down this path, TapRooT® makes you verify that the problem was caused by a natural event that was outside of your control.

I have seen people try to select Natural Disaster because there was a rainstorm, and a leak in the roof caused damage to equipment inside the building. Using TapRooT®, this would most likely NOT meet the TapRooT® Dictionary® definition of Natural Disaster. In this case, we would want to look at why the roof leaked. There should have been multiple safeguards in place to prevent this. We might find that:

The roofing material was improperly installed.
We do not do any inspections of our roof.
We have noted minor water damage before, but did not take action.
We have deferred maintenance on the roof due to budget, etc.

Therefore, the leaky roof would not be Natural Disaster, but a Human Performance issue.

The case of the meteorite strike, however, is a different issue. There are no reasonable mitigations that an organization can put in place that would prevent injury due to a meteorite. This is just one of those times that you verify that your emergency response was appropriate (Did we call the correct people? Did medical aid arrive as expected?). If we find no issues with our response, we can conclude that this was a Natural Disaster, and there are no root causes that could have prevented or mitigated the accident.

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