On May 29, 2012 a man boarded a flight from the tarmac at San Diego International Airport. The man did not have a ticket, and had not been through security. The extra passenger was not noticed until a flight attendant’s head count was noted to be off.
We can examine this issue in a Cause Map, which is a root cause analysis that visually represents the cause-and-effect relationships that result in impacts to the organization’s goals. We begin by defining what those impacts to the goals were. In this instance, although no one was hurt, there was the potential for a safety issue. The customer service goal was impacted due to the deplaning required for the passengers already onboard. The schedule goal was impacted because the plane was delayed due to the rechecks required of passengers. The personnel time required for these rechecks is an impact to the labor goal.
Once we’ve determined the impacts to the goals, we ask “why” questions to determine the causes resulting in the impacted goals. In this case, the rechecks were required because the flight attendant’s head count was off. The flight attendant’s count was off because a man without a ticket had boarded the plane. Because the man was able to board the plane from the tarmac without showing a ticket, tickets were presumably not checked at the aircraft door. Likely they were instead checked at the door leading to the tarmac. Because the unticketed man was able to access the tarmac through an emergency exit, he was able to get on the plane without a ticket. How was he able to access the tarmac? He went through an emergency exit door in a public area. Security did not realize that he had exited this way, either because there was no alarm associated with using the door, or the notification from the alarm was inadequate to ensure that security was notified.
According to San Diego Harbor Police Chief John Bolduc, “He completely bypassed TSA screening. He was in a public area and went out an emergency fire door, which gave him access to the tarmac.”
The airport is carefully scrutinizing its security to ensure that this never happens again. One solution would be to install emergency exit alarms so that security personnel are notified that security bypass procedures should be initiated. A solution for the plane operators is to check tickets at the door of the plane, in addition to or instead of at the exit to the tarmac.
To view the Outline, Cause Map and potential solutions, please click “Download PDF” above.