Introduction to the Role of Root Cause within an Aviation Environment

Posted by on
  • Hits: 416

Sofema Online (SOL) www.sofemaonline.com  Considers the key aspects of subject elements together with a deep understanding of both Root Cause & Contributing Factors

Introduction

Root cause analysis in aviation is not just about addressing the immediate issues that led to an incident. It’s about developing a culture of continuous improvement and safety throughout the organisation.

The findings from RCA should ideally lead to improvements. However, implementing changes in a highly complex and often cost-sensitive environment like aviation can encounter resistance. Investments in training changes to procedures or equipment upgrades can be substantial, and there is often a need to demonstrate a clear return on investment.

To achieve a successful outcome requires a commitment from all business area owners managers as well as the leadership team.

• The challenge is maintaining this commitment in the face of operational demands and economic pressures.

• Implementing the findings from RCA can be challenging due to the costs associated with training, procedural changes, or equipment upgrades.

• It is not unusual to demand a clear demonstration of return on investment before substantial changes are made.

What are the Expected Outcomes?

• To ensure compliance with any applicable regulation

• Preventing repeat findings and repeat incidents.

• To understand the problem in detail

• To investigate the causal factors

• To learn from the event

• To make future improvements to the system & process

Primary RCA Objectives:

• The key aim of RCA is to prevent recurrence. The challenge lies in identifying not just the obvious symptoms but the underlying causes that may be less apparent.

>> A thorough analysis that leads to effective preventive actions can be resource-intensive and requires a high level of expertise.

• Typically, understanding the problem requires an in-depth knowledge of the various factors that contribute to the expected system behaviour.

>> Includes technical understanding of human factors, environmental considerations etc

>> The challenge is compounded by the potential for biases that can lead investigators to premature conclusions.

Contributing Factors

The effectiveness of RCA hinges on a holistic understanding of all contributing factors, not just the immediate cause. This comprehensive approach is necessary due to the interconnected nature of aviation systems, where multiple layers of failure can lead to an incident.

Contributing factors can create a causal chain leading to an event. Each link in the chain is a potential point of intervention where a safety barrier could have prevented the incident.

For example, an equipment failure might lead to an incident only if all other safety barriers designed to catch that failure also fail.

Understanding how these barriers failed can be as crucial as understanding the initial technical failure. To deliver effective RCA, it’s necessary to identify and address not just the root cause but also the multiple contributing factors.

>> By doing so, organizations can develop comprehensive intervention strategies that address the fundamental issues and mitigate the impact of the contributing factors.

>> Aviation incidents often have multiple contributing factors, which can be a mix of technical malfunctions, human errors, and systemic issues.

>> A considerable number of aviation incidents involve human factors as contributing elements. These can include fatigue, miscommunication, inadequate training, or lapses in judgment. While they may not be root causes, they can significantly impact the outcome of an incident.

Next Step

For guidance on available courses, please see Sofema Aviation ServicesSofema Online or email [email protected].

Rate this blog entry:
1