1 Problem

loss of flight 17 over Ukraine Cause Map

What Problem(s) Plane shot down, crash, fatalities
When Date July 17, 2014 How to protect commercial airliners from ground conflict
Time 14:15 UTC On July 17, 2014, Malaysian Airlines flight 17 was shot down 33,000' above Ukraine by a surface-to-air missile.
Different, unusual, unique Flying over conflict area/ restricted airspace Just a week prior a military transport plane was shot down at 21,000'. The restricted airspace over the area
ended at 32,000'.
Where Facility, site Hrabove, Ukraine
Unit, area, equipment Malaysian Airlines flight 17 "I'm hoping in the next few weeks in the aftermath of this tragedy that we can get around the table and at least
Task being performed Flying above restricted airspace (~33,000') start having some brainstorming sessions to see what can be improved."
Impact to the Goals - Tim Clark, president of Dubai's Emirates, regarding an international conference of carriers to
Safety All 298 passengers & crew killed respond to the disaster
Environmental ?
Customer Service Plane struck by missile
Regulatory ?
Production/ Schedule ?
Property/ Equipment Loss of plane Why?
Labor/ Time Investigation Effect Cause
Airspace
NOTE: Read the Cause Map from left to right with the restrictions
Frequency 70 commercial plane crashes so far in 2014 phrase "Was Caused By" in place of each arrow. determined by
countries

Primarily concern
2 Analysis AND shoulder-fired
Possible solution:
missiles with
More Detailed Cause Map Directive to better range <32,000'
Basic Level Cause Map - Start with simple Why questions. Add detail as information becomes available. determine restricted Planes not
airspaces based on Airspace closed
restricted from AND
conflict for <32,000'
area
All 298 Planes not
Safety Goal Plane struck by Possible solution:
passengers, restricted from Concerns over
Impacted a missile Check path of flight
crew killed area missiles in area
All 298 AND
Safety Goal
passengers &
Impacted Evidence: A week
crew killed Plane in area AND prior, a military
3 Solutions Aircraft transport plane was
shot down at 21,000'
traveling at
Possible solution: 33,000'
Regulatory bodies, including the International Civil Aviation Organization (ICAO, the air- Customer Use of anti-missile
safety arm of the United Nations), are now looking at "the respective roles of states, Service Goal devices
Impacted Route based on
airlines and international organizations for assessing the risk of airspace affected by armed winds, weather,
conflict." Currently each government determines the risk and whether airspace should be Plane struck by AND congestion
a missile
restricted. Air-safety experts say Ukraine's restrictions weren't unusual. Says air-safety
consultant John Cox, "There has never been an airliner shot down from a surface-to-air Property/
missile at this kind of altitude. The threat has always been a shoulder-fired missile from Equipment Loss of plane
Goal Impacted Conflict in area
insurgents."

Individual airlines are also considering what they can do to reduce their risk. Some airlines
are even considering antimissile devices, which use laser beams to draw heat-seeking Missile in area AND
Labor/ Time
missiles away from the plane itself. However, these are only effective against shoulder- Investigation
Goal Impacted Unable to
fired heat-seeking missiles, not the type of missile that brought down flight 17. While many Evidence: Many
ground to air missiles distinguish
countries use these types of protection for their military planes, only Israel has required can now surpass between
their use on commercial airliners. 40,000' civilian, military For a free copy of our Root Cause Analysis Template in Microsoft
Evidence: Per Excel, used to create this page, visit our web site.
For individual passengers who are concerned about the route their plane may be taking, military experts, the
system used is
flight-tracking services will allow them to see the flight paths of the most recent flights. "particularly inept" at
However, because of gaps in coverage, flight paths over certain areas (such as over North distinguishing
Korea) may not be accurate. Airlines are being pressured to release their typical flight between civilian and Investigate Problems. Prevent Problems.
military aircraft Houston, Texas 281-412-7766 ThinkReliability.com
paths.
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