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Deadly Plane Crash Cause-And-Effect Relationships Supported with Evidence

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Deadly Plane Crash Cause-And-Effect Relationships Supported with Evidence Cause Mapping is a Root Cause Analysis method that captures basic 1 Problem Deadly Plane Crash cause-and-effect relationships supported with evidence. Cause Map What Problem(s) Plane crash Cause Mapping When Date February 4, 2015 Problem Solving • Incident Investigation • Root Cause Analysis Time 10:54 A.M. Plane Crashed Into River in Taiwan What's the Different, unusual, unique ? 1 Step 1. Problem Problem? Where Facility, site Keelung River, near Taipei Songshan Airport On February 4, 2015, there were 58 passengers onboard TransAsia Airways Unit, area, equipment ATR 72-6000 twin turboprop Flight 235 when the plane crashed into the Keelung River shortly after taking Why did it Task being performed Flying from Taipei to Kinmen off from the Taipei Shonshan Airport. There were 15 survivors from this Step 2.2 Analysis happen? Impact to the Goals dramatic crash where the plane hit a bridge and taxi cab prior to turning upside Safety 40 killed, 15 injured, 3 missing down and hitting the river. What will be 3 Solutions Environmental ? Step 3. done? Customer Service Negative publicity for airline Regulatory Carrier banned from adding new international flights Production/ Schedule At least 122 domestic flights canceled "It's a mistake...There are procedures that pilots go through - safeguards - Property/ Equipment Significant damage to plane when you're going to shut down an engine, particularly close to the ground. Why? Damage to bridge and taxi Why that didn't occur here, I don't know." Labor/ Time Major investigation/ recovery effort required Effect Cause - John M. Cox, former US Airways pilot and safety consultant Frequency 2nd fatal crash for TransAsia Airlines in a year NOTE: Read the Cause Map from left to right with the phrase "Was Caused By" in place of each arrow. 2 Analysis Property/ Solution: Damage to Equipment Hit by airplane bridge and taxi Goal Impacted Effect Cause Evidence: Major One engine idled Mechanical Labor/ Time investigation/ after takeoff failure? Goal Impacted recovery effort required 58 people onboard plane Evidence: Info from the flight data Customer Negative recorder shows an Service Goal publicity for 40 killed, 15 alarm registered 37 seconds after takeoff Impacted airline injured, 3 AND Pilots unable to Both engines in the right engine Evidence: Covered by missing control plane shut down international media Evidence: Media Significant AND reports of accident Significant damage to plane Pilot unable to Safety Goal Not enough time Plane was low to Plane had just restart second Impacted before crash the ground taken off engine? Plane crashed Property/ into river Equipment Plane crashed Goal Impacted AND Evidence: Video, eye witness accounts Carrier banned AND Pilot shut down Regulatory from adding new only working Goal Impacted international Pilotengine shut down ? Previous safety flights Previous recent Evidence: Info from the For a free copy of our Root Cause Analysis Template in concerns about aircraft crash flight data recorder Microsoft Excel, used to create this page, visit our web site. airline indicates the left engine was shut down Evidence: a TransAsia by one of the pilots plane crash in July 2014 killed 49 Investigate Problems. Prevent Problems. AND Houston, Texas 281-412-7766 ThinkReliability.com Production/ At least 122 Pilots being Concern over Pilot actions Schedule Goal domestic flights retrained and re- qualify of pilot believed to have Copyright ThinkReliability 2015 Impacted canceled qualified training led to crash Photo taken by dashboard camera of TransAsia Airways Flight Evidence: The airline has Plane could seconds before it crash into the river. stated that all the ATR safety fly with Photo uploaded to Wikipedia by user Veggies. pilots would retake one engine proficiency examinations working.
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