“No fault, just an accident”


Explosions rock downtown Dallas | Latest News | WFAA.com

Working from home with this news on in the background, the massive gas cylinder explosions at a business near downtown Dallas, about 30 miles from my home.

What jumped out at me was the TV reporter probing “whose fault was this?” and the fire inspector/spokesman said:

“There's no fault, it's just an accident. We need to find out why this happened.”

It's a horrible looking scene. A few burn victims, let's hope for their survival and recovery.

The spokesman was talking about some equipment failures/flaws that led to the chain reaction of explosions. It will be interesting to see if there is true root cause investigation (the Feds are headed in, for what that's worth) or if it eventually comes out that it was “somebody's fault.”

It might be the fault of one person, but would you suppose this is more likely caused by something systemic and preventable? The video certainly was scary, the tanks flying through the air onto roads and over the freeway.

With Lean problem solving, we need to ask “why?” and not first look for “who?”. Are fire investigators, by training, good root cause problem solvers? On the news, I'm hearing a lot of “why?” Why did this happen? Why are sites like this so close to downtown and major freeways? Many root causes are contributing to what could have been a much more lethal situation.


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Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus.

1 Comment
  1. Tom Southworth says

    As a firefighter I can state that yes, properly trained fire investigators are very good at searching out the root cause of a fire. Burn patterns, depth of the char, extent of smoke and heat damage, etc, all help point the investigator to the cause.

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