Common Errors in Aviation Root Cause Analysis (RCA)

Steve Bentley CEO of Sofema Group (www.sassofia.com www.sofemaonline.com www.aets-sofema.com) considers the common errors that people make when considering Aviation Errors

Lack of Detail of Appreciation Related to the initial assessment of the Event, Issue or Problem

Spending time to analyze the initial problem so that we understand “What” has happened as well as “How” it happened. It is important to perform this analysis before moving onto Root Cause Analysis.

This will not only determine the nature of the problem but will also identify exactly where the problem exists within the system, to understand when it exists. So, it is important to recognize that a well defined Problem Statement drives the entire Root Cause Analysis effort.

Insufficient Validation of the Root Causes

We have to consider that we are looking at an environment where multiple contributing elements, as well as potential multiple root causes come into play. When conducting a Root Cause Analysis we need to pull all this understanding together and an ishikawa fishbone diagram is ideal for this purpose.

To focus on each root cause which is identified (or potentially identified) to confirm that it is a root cause and not a contributing factor.

Note: Both Root Causes, as well as Contributing Causes, need to be addressed but it is usually more important to ensure the correct level of attention is provided to the “higher value” Root Causes. By addressing we mean to be in a position to “test” or “validate” the identified exposure.

Not Going Deep Enough into the Root Cause Analysis (RCA) Process  

Achieving the correct depth of RCA has always been a question of “Balance” ultimately off course we have to go the depth which is necessary to prevent the re-occurrence of the problem or issue.

Note that it is possible that the Root Cause is not the “Element” we have identified but rather if we go one step deeper we understand that it is indeed the management system which has failed to identify this “Element” as a “ system exposure”

So lack of preventative measures can influence the event we are trying to examine.

Organisational Culture and Well Being Issues impacting Effectiveness of RCA Activities

Identifying a training need, lack of leadership or management are typically not root causes. (Yes, agreed they are contributing causes – but the “Root Cause” will be found deeper)

Moreover, it is not unusual to find a RCA approach that overfocuses on analysis of a particular event in isolation and within linear organization limits. Resulting in localized recovery and action plans which do not go deep enough and which do not disseminate learned lessons to a wider audience.

Lack of Understanding Concerning Multiple Root Causes

When conducting Root Cause Analysis, it will typically be discovered that there are multiple causes to be uncovered related to a particular problem’s existence, with each root cause having its own level of contribution to the problem.

It is important to focus mitigations and improvement activities based upon the value/ weight of contribution of each root & contributing cause to the overall problem. 

Sofema Aviation Services and Sofema Online provide EASA Compliant Regulatory & Vocational Training including Quality & Safety Assurance and Root Cause Analysis Techniques.

Please see the websites or email: office@sassofia.com or online@sassofia.com