Attempted Bombing of Flight 253
Cause Mapping Example:
Despite constantly increasing airport security, a man suspected of terrorism was able to board Flight 253 from Amsterdam to Detroit on Christmas day (2009) with ~80 grams of explosive and a liquid detonator. However, the device did not detonate, likely saving the plane.
We can look at the causes of this incident by applying the Cause Mapping process. The three steps of the process are 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions. Each step will be discussed below.
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 attempted bombing. Another person might say that the problem was a fire on the plane, and a third person could say that the problem was that an explosive device was allowed on the plane. We can write down these three “problems” on the first line. In the Cause Mapping methodology the 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. The attempted bombing occurred on December 25, 2009. The exact time is unknown, but it was during the final approach from Amsterdam to Detroit. It's important to note in the "different" category that the suspect was allowed to board with explosives. Obviously this is not typical of air travel.
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. Here the incident occurred on Northwest Airlines Flight 253, which was an Airbus 330 on the final approach to Detroit's airport.
The next section is the impact to the overall goals. In any industry, there's a goal for zero fatalities. Although everyone on the plane survived, there was certainly the potential for the loss of all onboard, which is an impact to the safety goal, as well as the loss of the plane, which is an impact to the property goal. Additionally, both the suspect and another passenger were burned. These are also impacts to the safety goal. The failure of safety procedures that allowed the explosives onto the plane could be considered an impact to the customer service goal. Additionally, the airline provided vouchers to all the passengers who were on the flight. Because of the magnitude of the potential of the loss of life, we'll focus on this goal. Note that even though this was just a potential impact to the goals, it's still our focus, because of the potential loss of life. The completed outline is shown below.
Step 2. Identify the Causes (The Analysis)
The analysis step is where the incident is broken down into causes which are captured on the Cause Map. The Cause Map starts by writing down the goals that were affected as defined in the problem outline. For the attempted bombing, we'll begin with the potential for a loss of life, which is an impact to the safety goal. This is the first cause-and-effect relationship in the analysis.
The analysis can continue by asking Why questions and moving to the right of either of the cause-and-effect relationships above. Why was there a potential for the loss of life? Because of the potential for the loss of the plane, which is an impact to the property goal.
The potential for the loss of the plane was caused by the potential for the detonation of explosives on the plane, and that the explosives were sufficient to blow a hole in the aircraft. We know this because government testing showed that 50 grams was sufficient to puncture the wall of the aircraft, and the suspect had approximately 80 grams. We add this evidence in a box directly below the cause it is related to for reference.
The potential detonation had two causes - the suspect boarded the plane with an explosive mixture (which could have led to an explosion) and the detonation was unsuccessful (which, luckily for the passengers, prevented the explosion). We have evidence in the form of witness statements that the device burst into flames instead of exploding, and an FBI analysis that determined the makeup of the explosive mixture.
The detonation was unsuccessful because the suspect was subdued by other passengers, the flame was doused by flight attendants and passengers, and the suspect had difficulty with the detonator. All of these causes led to the unsuccessful detonation, so we join them with "AND".
Why was there difficulty with the detonator? Well, the suspect used a liquid detonator, probably because a solid detonator would have showed up on an x-ray or metal detector (which ALL passengers and carry-on bags go through) and liquid detonators are more difficult to use. It has been noted that the knowledge that a solid detonator would not get on board undetected is an example of how the current security restrictions helped save the plane.
Now that we've discussed why the device did not explode, let's look at how the suspect was able to board the plane with an explosive mixture. First, the suspect was allowed to board the plane. Second, the explosive ingredients were not detected by security. We'll look at each of these causes in more detail.
The suspect was allowed to board the plane because his visa was not revoked. Officials in the U.S. were unaware that a visa had been issued by the U.S. Embassy in London, and there was no follow-up on the information entered on the suspect into TIDE (the terrorist intelligence database). The suspect's father provided warnings about his son's questionable activities, and this information was entered into TIDE, but was not followed up on. It's unclear if a follow-up was not required, or if the follow-up procedure was not followed. The suspect was also allowed to board the plane because he was not added to the no-fly list, since the information from his father was considered insufficient to add him to the list. (Information is required to meet a "reasonable suspicion" standard.)
The explosive ingredients were not detected by security because the ingredients were hidden under the suspect's clothing, and because of an admitted failure of safety procedures. (This is an impact to the customer service goal.) The suspect was not given additional screenings because he was not added to the selectee list, which would have required additional security checks because, as above, the information known was considered insufficient for the "reasonable suspicion" standard. Additionally, the suspect was not passed through a body scan (which might have detected the explosives) because it is prohibited from being used on passengers traveling to the U.S. due to privacy issues.
Because some of the issues raised by the Cause Map are process issues, it will be helpful to draw a process map of the intelligence/security issues. A process map shows the steps as part of a given procedure. Once the process map is outlined to show what should happen, we can identify where errors occur, or where changes need to be made. The process map is shown on the downloadable PDF. To download the PDF, click on "Download PDF" at the top of this page.
Step 3. Select the Best Solutions (Reduce the Risk)
Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals. Once the Cause Map is built to a sufficient level of detail with supporting evidence the solutions step can be started. The Cause Map is used to identify all the possible solutions for given issue so that the best solutions can be selected. It is easier to identify many possible solutions from the detailed Cause Map than the oversimplified high level analysis. Airport security officials are already putting solutions in place to prevent an incident like this from ever happening again.
Cause Mapping Improves Problem Solving Skills
The Cause Mapping method focuses on the basics of the cause-and-effect principle so that it can be applied consistently to day-to-day issues as well as catastrophic, high risk issues. The steps of Cause Mapping are the same, but the level of detail is different. Focusing on the basics of the cause-and-effect principle make the Cause Mapping approach to root cause analysis a simple and effective method for investigating safety, environmental, compliance, customer, production, equipment or service issues.
Click on "Download PDF" above to download a PDF showing the Root Cause Analysis Investigation.