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Additional Products Transcripts: Easy American Idioms Audio: Drive Time English Audio: Complete Courses Glossary and Audio Lessons: Easy English Vocabulary Audio Scripts: Starting Out In Programs Audio Scripts: Root cause analysis is a powerful tool for doing so.
As we have demonstrated in our coverage of similar incidents in spaceflight, the Cause Mapping approach to root cause analysis analyzes incidents in terms of a detailed chain of cause and effect, promoting a better general understanding of the event at hand as well as multiple opportunities to enact solutions that prevent such catastrophes from happening again.
Cause Maps break incidents down into their individual contributing elements and are thus fantastic tools for understanding disasters like these see space maps fully and deeply. Our snapshot of the Concorde incident begins with a detailed picture of the incident—what happened—before we get into asking why.
Below you will find our problem summary for the Concorde disaster, including the problem, the time and location, and the industry goals that were affected by the event. First, it prevents a root cause analysis free-for-all that fails to stick to the roots of the incident. Focusing on problems leads to blame and arguments rather than to proactive problem-solving.
Focusing on problems also removes the team performing the root cause analysis from the key purpose of the discussion in the first place: to make for a better future for the organization and all involved.
So, instead of asking what went wrong this can elicit a number of answers, some more productive than others , we start with our goals as they relate to the ideal state of the airline. Naturally, fatalities are bad. Resource loss is also bad, but most people would agree that an organization that loses money but not lives is closer to its ideal state than one that saves money but loses lives.
The number of fatalities- is broken into two separate causes of a safety goal incident because it is useful for us to remember that some were killed because they were on the plane and some were killed because they were in the hotel.
The 5 Whys Technique is a way to kickstart any root cause analysis because it immediately creates building blocks for your cause map. Why did we have fatalities? Because the Concorde crashed. A piece of debris on the runway caused one of the left side tires to disintegrate. When the tires exploded a piece hit the underside of the aircraft, which ruptured one of the fuel cells slightly ahead of the intakes to the engines 1 and 2.
The fuel, which ignited, choked out the two engines on the left side, and the Concorde crashed into a hotel in Gonesse, France just 5 km from the runway. The Cause Map Continues This approach to root cause analysis is an excellent way to approach any issue because of the basic structure it provides. At the time, with a record of zero accidents per km traveled before the accident, the Concorde qualified as the safest airliner in the world.
Nonetheless, the crash of Air France Flight marked the beginning of the end for the mythic airliner. Both Continental Airlines and John Taylor, one of its mechanics, were found criminally responsible for their part in the disaster in December , but their convictions were overturned in a French court in , on the grounds that the mistakes that they made did not amount to criminal responsibility.
The first passenger flight in the wake of the accident took to the skies on September 11, , and touched down just before the world trade center attacks for which that date is better remembered. High Reliability Organizations- Quick Root Cause Analysis Note on Airlines Airlines are generally thought of as high-reliability organizations because there are over 87, flights per day in the United States alone according to the National Air Traffic Controllers Association , yet we have not seen a fatal major airline crash in the United States since November of when an American Airlines flight A crashed into a residential neighborhood in Queens, New York, not far from the departing airport.
Killed 5 on the ground, all 9 crew members and passengers, and damaged several homes. In that incident, the airplane had broken up while in flight—having shed its vertical stabilizer, left rudder, and engines, the plane spiraled out of control and landed on a house. Though such incidents are by their nature dramatic and thus widely reported when they occur, aviation is generally a high reliability—a safe—industry. Of the of the 34, transportation fatalities in , only related to aviation.
Part of the key to high reliability is following procedure- every time. Do we really have to go through our checklist every time?
Every time. Bless the Checklist Without a checklist, an organization begins to lack order.