Root Cause Challenges for Aviation Leaders
Steve Bentley CEO of Sofema Group (www.sassofia.com www.sofemaonline.com www.aets-sofema.com) considers the issues typically connected with a lack of “Management Team” engagement when considering Aviation Errors and the potential consequences which result.
Root Cause Analysis – Good, Bad, or Indifferent - How Was it For You?
Since Jan 2020 Sofema Has awarded over 20,000 Certificates to Delegates. It is fair to say that our level of engagement with the Industry places us in a unique position to understand many of the problems and the resultant pain which our clients feel.
When we “dig” into this a little further we understand that the process of Root Cause Analysis is not “delivering” in the way we know it can!
» In some cases we see the Regulatory Authority Pushing Back against the identified Cause of a finding.
» In many examples, the entire process is not sufficiently engaged to understand not just the Root Cause but the Contributing Courses (an essential aspect of driving effective process improvements)
» Business Leaders are often searching for a “Root Cause” as if it is in some way a single factor which once addressed will take the pain away!
Using Best Efforts for Initial Assessment
It is important that we use our best efforts to determine the nature of the problem and that we are able to identify exactly where the problem exists within the system, to understand when it exists.
A good outcome of this activity will deliver a “well defined” Problem Statement which we can then use to drives the entire Root Cause Analysis effort.
Root Cause Analysis – How to Make a Difference
» Spend time to analyze the initial problem
o so that we understand “What” has happened as well as “How” it happened.
Note - It is important to perform this initial level of analysis before moving onto the deeper level of Root Cause Analysis.
Lack of Detail of Appreciation Related to the initial assessment of the Event, Issue, or Problem - Important Note for Executives
A lack of understanding related to the value of Root Cause and the belief that there are clear lines of cause and effect without fully engaging in nature and contributors to the problem, causes the entire process to underperform
Every Event which is subjected to RCA provides a learning opportunity within the business process and will typically impact multiple business areas including some or all of the following.
» Manpower
» Communication
» Training
» Facilities
» Process & Procedures
» Oversight
» End-User Acceptance
Here’s a Take Away - The worst outcome for you as a business leader is to “go low” which means the search for a quick answer – with minimal action on your part.
Validation of the Root & Contributing Causes
We do not live in a world where there is a single “Root Cause” for all the issues which we are able to identify. We should understand that we are in an organizational environment where we have many Contributing Factors as well as multiple Root Causes. Moreover, for each factor, we should ideally develop mitigation.
Do not make the mistake of
» Only focusing on Root Causes – Contributing Causes can also become deadly precursors
» Stopping at a Contributing Factor believing that you have found the Root Cause when you can go deeper (A very common mistake)
» Believing Human Factors is a Root Cause – it is not!
Next Step
Please take a look at this course which is designed for Senior Managers to support Quality & Root Cause Objectives
Aviation Quality Auditing & Root Cause Analysis for Nominated Persons and Business Area Managers
For Free Resource to support Fishbone & Five Why Analysis – please see the following Link
https://sassofia.com/download-area/#safety-safety-management-system-sms
Please see www.sassofia.com and www.sofemaonline.com for any comments questions or support email team@sassofia.com
