Step 1: Define the Problem

The first step of the Cause Mapping approach is to define the problem by asking the four questions: What is the problem? When did it happen? Where did it happen? And how did it impact the goals? One person may say that the problem was the grounding of VALDEZ. Another person might say that the problem was that over 10 million gallons of oil was spilled, and a third person could say that the problem was navigational error. We can write down these three “problems” on the first line. In the Cause Mapping methodology the root cause analysis facilitator anticipates that the group may disagree so all three responses are written down. There is no need to spend time debating the problem. The magnitude of this incident is defined by the impact to the goals.

The second question is the “When?” which is the date and time of the incident. When captures the timing of the issue and also has a line for what was different or unusual in this occurrence. The question of what was different is fundamental in any investigation. On the VALDEZ issue we capture the date as March 24th, 1989 and the time of 12:09 a.m. when the VALDEZ grounded.  One of the key differences in this case is that there were icebergs in the shipping lanes.

In an investigation there can be several pieces of information that need to be captured when specifying the location. At a minimum the physical/geographic location and the process should be captured.   The physical location is where geographically the incident happened.  The VALDEZ grounded in Prince William Sound near Valdez, Alaska while transporting crude oil to California. 

(Photo courtesy of the  Exxon Valdez Oil Spill Trustee Council.)

The next section is the impact to the overall goals. On oil tankers, one of the overall goals is to have zero release. VALDEZ released approximately 258,000 barrels (10.8 million gallons) of crude oil, impacting the environmental goal, and also the material goal, since the leaked oil was worth $3.4 million.  The costs of cleanup were $2.2 billion, and there was $25 million worth of damage to the vessel.  Additionally, Exxon Corp. has paid approximately $1.5 billion for civil and criminal charges, including $507 million in punitive damages (reduced from $2 billion by the Supreme Court in 2008).  We’ll consider fines & punitive damages to be a customer service impact.  The three goals that are impacted in the VALDEZ example are the environmental goal, the customer service goal and the material goal.  

This completes the first step of the root cause analysis investigation.


Go to:


Step 1. Define the Problem

Step 2. Identify the Causes (The Analysis)  – Page 1Page 2

Step 3. Select the Best Solutions (Reduce the Risk)

Download the one-page PDF summary of the EXXON Oil Spill Root Cause Analysis.

 This example was made using our root cause analysis template.