By Kim Smiley
On Friday September 26, 2014, air traffic was grounded for hours in the Chicago region following a fire in a Federal Aviation Administration facility in Aurora, Illinois. The snarl of flight issues impacted thousands of travelers in the days following the fire as airports struggled to deal with the aftermath of more than 4,000 canceled flights and thousands more delayed.
A Cause Map, a format for performing a visual root cause analysis, can be used to analyze this issue. To build a Cause Map, the first step is to define the problem by determining how the overall organizational goals are impacted. In this example, there is a significant customer service impact because thousands of passengers had their travel plans disrupted. The flight cancelations and delays can be considered an impact to the production/schedule goal. The amount of time and energy needed to address the flight disruptions along with the investigation into the issue would also be impacts to the labor goal. Once the impacts to the goals are determined, the Cause Map is built by asking “why” questions and visually laying out the answers to show the cause-and-effect relationship.
Thousands of flights were canceled because air traffic control was unable to support them. Air traffic control couldn’t perform their usual function because there was a fire in a building that provided air traffic support for a large portion of the upper Midwest and it wasn’t possible to quickly provide air traffic support from another location. Focusing on the fire itself first, the fire appears to have been intentionally set by a contractor who worked in the building. He was able to bring in flammable materials and start a fire without anyone stopping him. Police are still investigating his motives, but he has been charged with a felony. The building was evacuated once the fire was discovered and employees obviously couldn’t perform their usual duties during that time. Additionally, the fire damaged equipment so air traffic control functionality could not be quickly restored once the initial crisis was addressed and it was safe to return to the building.
The second portion of the issue is that there wasn’t a way to support air traffic once the building was evacuated. Once the fire occurred, all flights were grounded because there wasn’t air traffic control support and it was not possible to quickly get air traffic moving again.
The final step in the Cause Mapping process is to develop and implement solutions to reduce the risk of a similar problem. Law makers have called for an investigation into this issue to see if there is sufficient redundancy in the air traffic control system. In an ideal situation, a fire or other crisis at any single location would not cripple US air traffic to the extent that this issue did. The investigation is also looking into the fire and reviewing the security at the facility to see if there should be stricter restrictions put in place, such as ensuring that no employees work alone or searching bags as workers access the site.
This situation is also a strong reminder that organizations need to have a plan in place of what to do in case a failure occurs. There was a previous fire scare at this same location earlier in 2014 when a smoking ceiling fan resulted in an evacuation and flight delays (see previous blog) that should have prompted some serious consideration of what the contingency plan should be if this facility was ever out of commission.
I was one of those people standing in line for hours at an airport on Friday morning after my flight was canceled. And I for one would love to see the air traffic control system become more robust and better able to deal with the inevitable hiccups that occur. It’s impossible to prevent every potential problem and another intentional fire in a FAA facility seems pretty farfetched, but it is possible to have a better plan in place to deal with issues that may arise. The potential consequences of any single failure can be limited with a good plan and quick implementation of that plan.