Death of Luger at 2010 Winter Olympics Even more detail can be added to this Cause Whistler Resort, Map as the analysis continues. As with any A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page. February 12, 2010 investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.

Solutions: Add Solutions: Add wooden wall to Desire for padding to steel prevent athletes commercial use pole from flying off track after Olympics Higher tourist traffic AND Flew off Track faster See same Hit steel pole Lost control track than typical cause More potential Safety Goal AND customers Impacted Evidence: Video of Evidence: Video of accident accident Blunt force One fatality trauma Whistler chosen Firmer, faster Colder climate AND as site for track ice Investigation Evidence: 1 luger Schedule Goal Design of track into accident killed during practice Few wide Impacted Solutions: Start Track faster limited by Evidence: Other run on track curves to events at lower than typical AND locations considered reduce speed topography of locations to reduce site had warmer speeds Evidence: Projected Evidence: Whistler's temperatures which A long, narrow top speeds were 96 track was 100 yds leads to mushier, site was only mpg, a 5.5% increase wide, compared with slower ice Traveling at option at 's 300 yds and high speed AND Whistler Salt Lade City's 500 AND Accident yds. occurred near Alpine events On February 12, 2010 , an Olympic luger from the country of final curve of were scheduled for Whistler Georgia, was killed during a practice run. He lost control of his sled, flew off the track track and hit a steel pole. Evidence: Athletics gain speed as they travel the track The investigation into the accident is still ongoing, but a root cause analysis can be started with the information that is available. This accident obviously impacts the How did the track get designed to be so much faster than typical tracks? There are a number of causes that contributed to safety goal because an athletic was killed and it also had potential to impact the fast design. The designers choose Whistler as the site of the track because Whistler has a colder climate than the schedule goal because the track was closed during the initial investigation. alternatives, resulting in firm, fast ice and because there is high tourist traffic there that would help make the track a commercial success after the Olympics. Whistler was also the site of the Olympic alpine events. There are a number of causes that can be added to the Cause Map. One of the more obvious causes for the accident is that the athletic was traveling at high speeds. This The land that was available at Whistler was long and narrow. The site was a valley approximately 100 yards by 800 yards. By occurred because the crash happened near the bottom of the track so the sled was comparison, the Calgary track was about 300 yards wide and 's track was 500 yards. Designing a track to fit in near its top speed. Additionally, the Vancouver Olympic track is also a particularly the available region meant the track couldn't include any long curves that slow down speed as is typical. fast track. Top speeds on the track were predicted to be 96 mph, nearly 6 miles faster than the standing 2000 world speed record. The result was the fastest track in the history of the sport.

Cause Map As the investigation continues, more details become available and they can be added to the Cause Map. Intermediate Level In order to ensure safety during the , several solutions were implemented following the accident. A wooden Why? wall was added to the curve where the accident occurred to keep athletics on the track, the steel poles were padded and events were started lower on the track to limit the maximum speed. The lower start was predicted to slow top speeds in the men's events by about 5 mph. Investigate Problems. Prevent Problems. Effect Cause Houston, Texas 281-412-7766 ThinkReliability.com NOTE: Read the Cause Map from left to right There have been several crashes on the course since the accident, but thankfully no farther significant injuries have occurred. with the phrase "Was Caused By" in place of each Copyright ThinkReliability 2009 arrow.