Tag Archives: evacuation

It’s Faster to Send a Rescue Mission to the International Space Station Than to the South Pole

By ThinkReliability Staff

Yes, you read that correctly. Says Ron Shemenski, a former physician for the station, “We were stuck in a place that’s harder to get to than the International Space Station. We know we’re on our own.” A sick astronaut on the International Space Station can jump in the return vehicle permanently parked at the station and make it back to earth in about 3.5 hours. In contrast, just to get a plane to the Amundsen-Scott South Pole research station takes 5 days – in good weather. Which is not at all the situation right now – at the South Pole it’s the very middle of winter.

This makes for an incredibly risky evacuation. It’s so risky that the scientists at the station expect to stay there from February to October, no matter what. The on-site physician biopsied and administered chemotherapy to herself in 1999. A scientist who suffered a stroke in 2011 had to wait until the next scheduled flight. However, winter medical evacuations have been performed twice before in the history of the station (since 1957), in April 2001 and September 2003. These two evacuations were performed by the same company that will perform this rescue. On June 14, the National Science Foundation (who runs the station) approved the medical evacuation of a scientist there. Two flights left Calgary, Canada that same day.

What makes the evacuation so risky that there is a debate over whether or not to rescue an ailing scientist? There are multiple factors that are considered in the decision. These issues can be developed within a cause-and-effect diagram, presented as a Cause Map. The first step in the process is to determine the impacts to the goals that result from a problem. In this case, we will look at the problem of a scientist at the South Pole becoming ill and requiring evacuation. There is an impact to the patient safety goal due to the delay of medical treatment. There’s also an impact to the safety of the aircrew on the flights used to rescue the scientist. There’s also an impact to property/ equipment and labor/ time due to the risky, complex evacuation process.

In the analysis (the second step of the process), the impacted goals become the effect in the first cause-and-effect relationships. The delay in medical treatment for the patient (the ailing scientist) results because required treatment is not available at the station, although a physician and physician’s assistant staff the clinic throughout the winter. There’s also a delay for the decision to send an evacuation plane. In this case, a day and a half of deliberation were required. As previously discussed, normally planes do not arrive at the station during the winter. It’s happened only twice previously in the last nearly 60 years. In order to ensure safety, the crew at the station undergoes a rigorous medical screening, to prevent illnesses requiring evacuation as much as possible.

Medical treatment is also delayed by the time required for the plane to arrive at the South Pole, and then for the plane to return the patient to a medical treatment center. (Which center is determined by the nature of the medical issue, which has not been disclosed, but the nearest centers are thousands of miles away.) The trip to the South Pole takes at least 5 days because of the complexity of the process. It also poses a risk to the air crews making the trip. (There are two planes sent in; one for evacuation and one to remain nearby in a search-and-rescue capability.)

The conditions in Antarctica are the cause of many of the difficulties. The sun set at the station in March, and will not rise again until September, so the plane must land without any daylight. It also has to land on packed snow/ ice, which requires skis, as there are no paved runways and the average winter temperature is -76°F (with wind chill it feels like -114°F). At those temperatures, most jet fuel freezes, so only certain planes can make the trip. (This is why they’re coming from Canada.) The planes can only hold 12-13 hours of fuel, and the last leg of the trip (across Antarctica) takes 10 hours (again, in good weather) so after a few hours into the flight, the plane has to either turn back, or they must land at the South Pole, regardless of conditions. Due to the desolation of the area, there’s nowhere else to land or refuel.

Currently one plane has made it to the South Pole, where it will wait for at least ten hours to allow the flight crew to rest and monitor the weather. The second plane remains at the Rothera Research Station, on Adelaide Island on the edge of Antarctica. Check for updates by clicking here. View the one-page downloadable Cause Map by clicking “Download PDF” above.


Explosion, Deaths at Maternity Hospital Follow Gas Leak

By ThinkReliability Staff

A gas tanker was providing fuel to a maternity hospital in Mexico City when the gas workers discovered a leak. They contacted the fire department, had the hospital evacuated, and attempted to put out the leak. Unfortunately, the leaked gas exploded, killing at least 2 nurses and 2 babies, and leveling most of the hospital.

Dozens more infants, patients and nursing staff were injured, along with the three gas workers present at the scene. The gas workers have all been arrested, though the charges against them have not been released. While it appears that the workers are being held responsible for the tragedy, providing an objective, factual analysis as to what happened can provide useful information to reduce the risk of the issue happening again.

When performing a root cause analysis of an issue (as we will do here in a Cause Map), it’s important to first capture the impacts to the organizational goals as a result of the incident being investigated. In this case, the patient safety goal is impacted because of the deaths of two infants and the injuries to dozens of patients. The safety of hospital employees was impacted due to the deaths of two nurses and injuries to many more. Additionally, the safety of the gas company employees was impacted because all three of the gas workers were injured.

The environment was impacted due to the gas leak. The compliance goal was impacted because the three workers were arrested. The patient services and operations goals were impacted by the evacuation from the hospital (which is very difficult on patients and staff, although it likely saved many lives in this case). The property goal is impacted because of the severe damage to the hospital and the labor goal is impacted by the rescue efforts. (Hospital neighbors are reported to have provided considerable assistance to the rescue efforts at no small risk to themselves.)

Any time deaths or injuries result from an explosion, it is important not only to determine what caused the explosion, but whether the response could have been improved. In this case, the explosion occurred while the hospital was being evacuated, though a specific timeline of the leak, evacuation and explosion has not been released. Further analysis into the evacuation will help determine whether improvements could have saved lives.

In the case of the explosion, the fuel was provided by the leaked gas. Adequate oxygen was present in the air, and the ignition source (heat) could have been provided by hospital operations (the gas was being delivered near the hospital kitchen) or potentially by work being done to repair the leak (such as static or a spark). The gas leaked due to a faulty gas delivery hose. When a faulty part contributes to a tragedy such as this one, it’s important to determine not only how the damage occurred (if possible), but whether inspections or maintenance could have reduced the risk of an incident. Clearly if the hose had been discovered to be faulty and replaced before the delivery took place, the risk of an explosion would have been greatly decreased.

A broader issue for the entire country is the question of why gas leaks and explosions are fairly common. Part of this is because there is no infrastructure to pipe gas underground and it instead has to be delivered by truck. A similar incident involving a hose issue on a gas truck killed three in Queretaro in July last year. The company that provided the gas to the hospital in this case says that it has 1,000 trucks that deliver gas to over 80% of the country. With such a large distribution network, accidents are bound to happen. However, clearly more effort needs to go into making sure that the impact on human lives is reduced.

NYC Hospital Unexpectedly Evacuated During Sandy

By Kim Smiley

On October 30, 2012, power outages forced evacuation of a New York City hospital amidst the onslaught of Hurricane Sandy.   All 217 patients in the hospital to had moved, including 20 infants staying in the neonatal intensive care unit.

This incident can be analyzed by building a Cause Map, an intuitive format for performing a root cause analysis.  The first step in the process is to fill in an Outline that lays out the basic background information and also identifies the impact to the goals.  In this example, the safety goal is clearly impacted because it is risky to evacuate patients during a hurricane.  Although the potential for injury was very real, no one was hurt during the evacuation and the hospital staff did an amazing job of carrying patients down darkened stairwells and ensuring basic life support remained stable.  The customer service goal is also worth considering since the unexpected evacuation received a large amount of negative publicity.

After the Outline is completed, the next step is to ask “why” questions to add Causes to the Cause Map.  Why were patients at risk?  This occurred because the hospital had to be evacuated because it lost power and the backup power generators failed.  Why the generators failed hasn’t been identified yet, but there is speculation that the age of the equipment may have played a role. It’s also possible that the location of the generators might be factor since a number of hospital building were flooded by ten feet of water.  Electrical service was lost because New York City was hit hard by Hurricane Sandy and saw unprecedented flooding and strong winds.  This wasn’t an unexpected impact of the storm, but the hospital did not expect the generators to fail, especially so quickly.  The patients were also at risk because the hospital had many patients in critical care units that required life support systems and the patients were evacuated under dangerous conditions, both inside and outside the hospital.  At the time of the evacuation the hospital had lost power and patients were being carried down stairs lit by flashlights.  Some patients were bought down 16 flights of stairs.  The evacuation also occurred during the hurricane so the conditions during the drive to a new faculty were potentially dangerous.  The evacuation occurred during the hurricane, as opposed to before the storm hit, because the hospital assured the city that it was prepared and could ride out the hurricane.

This issue is still being investigated, but once all the facts are known solutions can be developed and implemented to help ensure that patients aren’t forced to evacuate under similar adverse conditions.

Click on “Download PDF” above to see a high level Cause Map of this issue.