Concorde - Cause Map
On July 25th, 2000 one of the Concorde Supersonic jets crashed near Paris, France killing all 109 people onboard in addition to 4 on the ground. A tire on the left side disintegrated while the aircraft was accelerating down runway 26R during take-off. A piece of the tire struck the underside of wing where fuel tank 5 is located. A pressure wave inside the tank caused it to rupture forward of the tire strike. Fuel poured from the tank and ignited. The Concorde had already reached a velocity where it could not stop safely by the end of the runway so it lifted off the runway with flames hanging from the left wing. There are some incredible photos that captured this amazing moment.
Define the Problem (Step 1. Problem Outline)
In the Cause Mapping method every problem is defined in an outline format by four basic questions: What, When, Where and Impact to Goals? For the Concorde incident, the first question, "What's the problem?" can be answered several different ways. Some people may see the problem as the Concorde crash, other people may see the problem as the loss of life and still others may say that the problem is the ruptured tire or the debris on the runway. In the Cause Mapping method it's unnecessary to debate "the problem." If there are four different points of view as to what the problem is all of them can be written down...quickly. A problem is not defined by individual points of view, but by the impact to the organization's overall goals. The goals provide the common ground for everyone to agree. People will disagree about the problem, but they don't disagree on the impact to the overall goals. The basic problem outline looks like this:
Notice that one of the overall goals is safety. Any organization that transports passengers has a goal of zero injuries. Even though there are different views of the problem everyone will agree on the impact to the goals.
Analyze the Causes (Step 2. Cause Map)
In the Cause Mapping method, the analysis step begins with the important to the overall goals, not "the problem." Starting with the goals is a subtle, but significant improvement in the way organization's define problems. The safety goal is zero injuries, but the Concorde accident resulted in 109 fatalities on the aircraft and 4 on the ground. These impacts to the safety goal are the starting points for cause-and-effect analysis. These can be captured as two different safety goals - the people on the aircraft and the people on the ground.
The Concorde crashing caused the 4 fatalities in the hotel and the 109 fatalities on the aircraft. The Cause Map, below, has two different effects, both losses of life, from one cause. By separating the two effects the Cause Map can show the two different ways the 113 people died.
The crash of the Concorde was caused by the loss of the two engines on the left side of the aircraft. A piece of debris on the runway caused one of 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 above is a simple 5-Why approach to root cause analysis. It's an excellent way to get started because of the basic structure it provides. From this point more detail can be added. Cause-and-effect relationships can be added to the left, right, in between and vertically from each one of the causes on the Cause Map. Look at the notes on the same Cause Map below.
The Cause Mapping method shows how the area in between any cause-and-effect relationship can be broken down into more detail. The word analysis is defined as breaking down into parts. A root cause analysis breaks an incident down into a sufficient level of detail to provide a clear explanation that is supported with objective evidence. A root cause analysis dissects an issue.
This section of the Cause Map below shows how detail can be added in an investigation. It's true that the fuel cell ruptured because the tire disintegrated, but to provide a complete explanation more detail needs to be added. Specifically, the fuel cell ruptured because the stress on the fuel cell exceeded the strength of the fuel cell. During the Concorde investigation it wasn't immediately clear whether the impact to the fuel cell was caused by a piece of the tire or by the rain/debris guard. These are possible causes. By following the evidence, investigators determined a 4+kg piece of tire struck the underside of the wing. When evidence disproves a hypothesis, the cause is not removed from the Cause Map, it's simply crossed out. The evidence that disproves the cause is placed beneath the cause.
The Concorde Cause Map Poster - Detailed Explanation
The poster of the Concorde Cause Map contains a basic and detailed analysis of the accident. The basic Cause Map starts with five Why questions. The detailed analysis of the Concorde accident contains over 100 cause-and-effect relationships. The solutions form the actual investigation are located above the particular cause it controls and summarized in a numbered table. Click here to order yours today.
