By Kim Smiley
On April 6, 2012, a Navy F-18 jet crashed into an apartment building in Virginia Beach, Virginia. Significant damage was done to the apartment building and the jet was destroyed, but amazingly no one was seriously injured or killed.
This incident can be analyzed by building a Cause Map, an intuitive, visual format for performing a root cause analysis. The first step when building a Cause Map is to determine how the incident affected the organizational goals. The impacts to the organizational goals are recorded in the Outline which also documents the background information of the incident. In this example, the safety goal was obviously impacted since there was potential for serious injuries. The property goal was also impacted because the jet was destroyed and the apartment building suffered extensive damage.
Once the Outline is complete, “why” questions are asked to determine what factors contributed to the incident. In this example, there was potential for injuries because a jet hit an apartment building. This occurred because the jet was flying near the residential area and the jet was unable to complete its attempted take off. The pilots could have been injured had they not been able to safety eject before the crash and there was potential for people on the ground to be injured since the jet crashed into a residential area. The jet crashed because it experienced a dual engine failure. The investigation into this crash determined that that both engines failed for two separate, unrelated reasons.
The right engine failed because of a catastrophic failure of the engine compressor when it ingested flammable liquid that was ignited. The left engine afterburner failed to light. Investigators believe that an electrical component failed, but the damage to the left engine was too severe for a conclusive determination of what exactly occurred. According to the Navy, this is the first unrelated dual engine failure of a F-18.
The Navy plans to update procedures to incorporate the possibilities of this type of incident.
To view a high level Cause Map of this issue, click on “Download PDF” above.