Investigation of the Root Cause of a Water Loss from a Toilet "Steam Tornado"

A water loss at a multi-story commercial facility reportedly started when a "steam tornado" was released from a toilet after it was flushed by an employee, causing the fire protection system to activate and flood the building. This presentation explores the investigation and root cause analysis techniques used to determine the sequence of failures that were required to lead to this condition at the subject toilet. A summary of the failed components in the water heating and plumbing systems, as well as procedural issues at the facility will be examined. In particular, this investigation will discuss the ways in which an understanding of mechanical systems as a whole may allow the investigator to draw firm conclusions about the cause(s) of a failure without the need for detailed testing and examination of specific damaged equipment or components.