Loss of Firefighting Plane Affects Firefighting Efforts

By ThinkReliability Staff

Wildfires in the Rocky Mountain region have been plaguing the nation for weeks.  The firefighting mission took a severe hit when a C-130 that was dropping flame retardant on the fire crashed on the evening of July 1, 2012, killing four of six crewmembers and injuring the other two.  As a result of the crash, the Air Force grounded other C-130s for two days, increasing the work for firefighters on the ground.

Although the Air Force has not released details of what exactly resulted in the plane crash, we can look at the information we do have available in a visual root cause analysis or Cause Map.  We begin by determining which of the organization’s goals were impacted in the Outline.  First, because of the deaths of the crewmembers, the safety goal was impacted.  The environmental and customer service goals were impacted because of the decreased ability to fight wildfires.  The schedule goal was impacted because other C-130s were grounded for two days.  The property goal was impacted because of the damage to the plane, and the labor goal was impacted due to the increased difficulty for remaining firefighters in fighting the fire.

Once we have determined these impacts to the goals, we can begin asking “Why” questions to draw out the cause-and-effect relationships that led to the impacted goals.  The safety, and other goals, were impacted due to the plane crash.  Again, although the Air Force has not released details of its ongoing investigation, it is believed that  downdraft (caused by the same high winds in the area that are helping to keep the wildfires travel) may have contributed to the crash.  An additional contributor is the fact that the plane was likely traveling at extremely low altitude, which allowed the plane to perform its task to help fight wildfires.  Lastly, it is possible that the heavy demands placed on the plane due to the extent of the fires may have contributed to the incident.  If, during the course of the investigation, it is determined that one of these causes was not related to the plane crash, the causes can be crossed out, but left on the map.  Evidence that shows that this cause did not result in the incident should be placed under the box.  This allows us to keep a complete record of which causes were considered.

Once the causes related to the incident have been placed on the map, solutions to mitigate the risk of this type of incident from happening again can be brainstormed and implemented.

To view the Outline and Cause Map, please click “Download PDF” above