On July 25th, 2000 one of the Concorde supersonic

jets crashed near Paris, France killing all 109

people onboard in addition to 4 on the ground. One
of the aircraft tires disintegrated during take-off,
rupturing a fuel cell. Fuel spilled into the intakes of
engines 1 & 2, choking the air flow and shutting
Cause Map - Basic cause-and-effect analysis (2-Why questions) them down. The pilot was attempting to circle
around and land, but the aircraft could not stay alof
with only two of four engines funtioning
Safety Goal Concorde Fuel cell
113 fatalities
Impacted crashed ruptured
There were 100 passengers
onboard the aircraft and nine The Concorde crashed because Debris was
crew members. It was a charted there wasn't sufficient thrust to orietated on its
flight that was heading to New keep it aloft. The aircraft needed 3 When the tire disintegrated a A piece of debris found on the edge
York as part of a 16-day cruise to of its 4 engines on take-off but only piece struck the underside of the runway after the Concorde Evidence: Lab tests showed
South America. the two engines on the right side wing on fuel cell 5. A shock wave accident matched the cut line that metal orientation on edge
on a piece of the exploded tire. required to puncture tire.
were functioning. The heat from inside the tank caused a rupture
the fire, which is not shown at this in a forward location on the tank. Any items that pose a threat to
Cause Map 8-Why questions
level of detail also affected the The tank didn't rupture where at the integrity of the aircraft are
Stress applied
control surfaces of the left wing. the location of the tire strike. known as foreign object debris
to Tire
Safety Goal 109 fatalities (FOD).
Impacted on aircraft
Test tire cut by metal strip

Tire AND
Concorde Loss of 2 Fuel cell Debris on
disintegrated,
crashed engines ruptured runway
exploded Debris, titanium
Tire rolled over
wear strip on
debris
Safety Goal 4 fatalities runway
Impacted in hotel Evidence: 75 m/s rotational Evidence: Metal strip found
The rupture in tank 5 was just slightly Runway 26R is x feet wide. The speed of tire at time of debris on runway matched to
debris (FOD) not only had to be in strike BEA report. Sept 3-03 previous aircraft.
ahead of the intakes of engines 1 and
Four people on the ground 2 on the left side of the aircraft. The the runway, it also had to be in
Evidence: Cut line shown in
were killed when the Concorde two engines experienced a flame-out the path of the tire. The piece of AND actual ruptured Concorde tire
crashed into a hotel located because of fuel entering the intakes. metal debris also had to be found on runway.
near the airport. The fuel pouring from tank 5 had also situated on it's edge in just the
ignited. precise way to cut into the tire.

Unusual
Cause Map - 20-Why questions take-off profile
Solution: Specify type of
permissible repair &
establish number of
Aircraft stalled, Solution: Increased re-laminations allowed
Safety Goal 109 (all) lost on AND
containment strength of
Impacted loss of lift
aircraft tires, failure puncture limits. Multiple
Solution: Increased tire re-laminations
Loss of Fuel entered Tire
Concorde Service Factor of tires of tires
engines intake, choked Fuel cell rupture disintegrated, from 2X to 4X
crashed into
#1 & #2 air flow exploded
hotel
Safety Goal 4 fatalities in AND
Strength of tire
Impacted hotel

Evidence: Upgraded from Higher

AND Excessive
issues in 1970's. Tire
temperature
Service Factor increased toe-in of
than normal for
to 2X damaged Tire
Property Goal tire
Loss of Aircraft
Impacted

Concorde Cause Map Poster

A detailed analysis of the Concorde accident with
Concorde Unable to abort 120-Why questions and the recommended solutions
airborne take-off from the BEA report. A valuable case study for
reviewing risks within your group.
Houston, Texas 281-412-7766 ThinkReliability.com Order a poster at www.thinkreliability.com
Copyright ThinkReliability 2009
(20" x 36")