1 Problem

Problem(s)
Explosion Kills 75 Cause Map
Cause Mapping is a Root Cause Analysis method that captures basic
cause-and-effect relationships supported with evidence.
What Auto parts factory explosion
When Date August 2, 2014 Cause Mapping
Time 7:37 AM Metal Dust Believed to Be Responsible Problem Solving • Incident Investigation • Root Cause Analysis

Different, unusual, unique
Facility, site
Where
Unit, area, equipment
Task being performed
Impact to the Goals
Safety
Regulatory
Production/ Schedule
Property/ Equipment
Labor/ Time
High levels of dust 75 workers were killed and about 186 were injured by an explosion at an auto What's the
parts factory in Kunshan, China. At the time, the workers were polishing Step 1. 1 Problem Problem?
Kunshan, China
hubcaps, a process that is known to create metal dust that can lead to dust
Auto parts factory explosions if safety regulations aren't carefully followed. Why did it
Polishing hubcaps Step 2.2 Analysis happen?
"The explosion at the factory in Kunshan illustrates once again that although
75 workers killed What will be
there are many laws and regulations outlining health and safety standards in Step 3.3 Solutions done?
~186 workers injured the workplace those standards are not properly enforced by local authorities."
Five executives detained
- Geoffrey Crothall, China Labor Bulletin
268 factories shut down
Damage to factory Why?
Three-month round of inspections Effect Cause

Frequency April dust explosion in Nantong killed 8; NOTE: Read the Cause Map from left to right with the
phrase "Was Caused By" in place of each arrow.
2012 explosion in Wenzhou killed 13; fire Solution:

alert from factory 2 months before Ignition source Spark?

Effect Cause
explosion
Evidence: Preliminary Evidence:

2 Analysis AND investigation

Cause Map - Add detail as information becomes available. Oxygen

75 workers killed (atmosphere)
Metal dust
Safety Goal Electroplating
AND created during
Impacted wheel hubs
process

~186 workers Metal dust

Fuel Insufficient
injured explosion
oversight by
Evidence: Preliminary Accumulation of government
AND AND
investigation metal dust
Insufficient
Property/ regulations AND
Damage to Dispersion regarding dust
Equipment
factory
Goal Impacted Insufficient
Subcontractors
Insufficient oversight by
managed by
AND
cleaning/ multinational
contractors
ventilation companies
AND
Confinement Evidence: Initial
(within building) investigation showed
Ignition These elements make up shortage of
Fuel source the dust explosion equipment to remove
pentagon & are required dust
for a dust explosion to Lack
Confinement Dispersion Lack of
of regard
regard "Extreme" cost Competitive
occur.
Regulatory Five executives for safety pressure market
Goal Impacted detained
Oxygen Evidence:
Evidence: Industrial Evidence:
3 Solutions accidents
Industrial
accidents kill
kill tens
tens of
of Subcontractor to
thousands
thousands annually
annually in in wheel manufacturer
China
China for car manufacturer
Production/
In response to the explosion, China has detained executives from the 268 factories For a free copy of our Root Cause Analysis Template in
Schedule Goal Microsoft Excel, used to create this page, visit our web site.
company, and has closed 268 factories that have the potential for shut down
Impacted
similar issues until they are given government permission to reopen. Three-month
The government is conducting what is expected to be a three-month round of
round of investigations of these factories and is expected to develop inspections
Investigate Problems. Prevent Problems.
regulations that will better protect workers from explosive dust Labor/ Time Houston, Texas 281-412-7766 ThinkReliability.com
conditions. Goal Impacted
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