Requirements and Methods for the Correct Identification of a Root Cause in Aviation Systems Exposure.

The process to understand the causal elements including the various Root Causes is a subjective process – means it can be influenced by personal behaviour. 

It is important for the reason that we should take careful steps to ensure the we have the necessary skill level and competence in the persons or teams who are responsible for the evaluation process. 

Team Composition

Any team which is assembled to consider Root Cause must have the Appropriate skill set and knowledge of Investigative Methodology. Background Knowledge and understanding related to Parts, Materials, Processes & Human Performance as required should be present as required.

Note the importance of ensuring Management Commitment to be successful in any given investigation the lead investigator and team members should be given

management backing to pursue the root cause in the most effective way

Gathering Classifying Data

Consider the need to avoid incorrect data classification – also the potential for assumptions to be used as a driver as opposed to the need to construct objective

evidence.

Always ensure that Data is Classified in accordance with a framework which recognises the need to classify accurately relative to observed facts

Structure of the Investigation Process 

The worst possible outcome would be for the lead investigator to be biased toward a

particular root cause and then to exert an influence on others within the team.

Ensure that the process flows in the correct way following the recognised steps. For example we must never begin with an assumption based on a likely root cause and then look for evidence to validate it, rather we should proceed by collecting all of the relevant data and facts and to use this through a process of analysis to drive us to  an objective root cause.

Always avoid a rush to judgment: The investigation is closed before all potential causes are investigated. Jumping to a probable cause is a major pitfall in root cause analysis (RCA). 

Time is Money!

How much time is allocated to an investigation should have a bearing on the cost of investigating. Consider it as a “Return on Investment”, where the investment is the time and effort and the return is the benefit or potential benefit to the organisation – which may be related to reduced exposure, financial benefit or could be reputation.

Sometimes the actual root cause may lead to a proposal for redesign which is not affordable for the organisation.

As a minimum the limited investigation will involve arriving at most likely root cause by examining a representative amount of data and not spend excessive time in gathering more data,

Sofema Aviation Service (www.sassofia.com) offers multiple EASA Compliant Regulatory Training Courses in Quality, Safety and Root Cause Techniques. For further information please emailoffice@sassofia.com.