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 about the fire …

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.” After that, the investigation becomes a criminal investigation.

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.

Root Cause Analysis
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