Safety Management Systems in Aviation – Root Cause Considerations

What do we mean by Root Cause? Often people have a bias to stopping at an event, which itself has enables or causes, however with practice it becomes easier to work through the process and achieve meaningful results.

Let’s take some time to De-Mystifying Root Cause, when we talk about Root Cause we are simply trying to understand why a “something” has happened – what where the fundamental causes and on the journey to discover as many of the contributing factors as we can.

So the focus is on “Why” and “How” a particular event or condition occurred so that we can develop the correct understanding.

One of the simplest tools we use is in fact called the 5 Why Analysis. It is simply a process of repeating the question why until we reach the most fundamental cause of our situation, or until we cannot go any further. In general asking why 5 times is as far as we need to go to address in a meaningful way the issue which has arisen.

It is important that we have a fundamental knowledge of the process or operation, but at the same time we do not allow ourselves to be biased by expectations. When asking the question Why it is important that we move through the levels in a systematic and relevant way not missing any of the steps and fore sure not allowing ourselves to jump to early conclusions.

Do not be perturbed if we stop at 3 or 4 questions conversely do not feel obliged to stop at 5 if you feel that there is more benefit of pressing on for a deeper understanding of the issues.

Do not leave any open ends, and do not assume there will only be a single root cause – remember that often there are multiple root causes. Often the finding of a root cause co-insides with a why answer which leads us to a policy or procedure or a person. (Consider that the “Person” as a selection may open up a whole new area associated with Training and Competence Management.)

At the end of our activity we should consider the relevance of our determinations and to ensure that if we address the issues in a meaningful way than we will prevent the event from re-occurring. To look at it in another way if the proposed fix, solution or “mitigation” had already been in place would it have precluded the event or issue from happening.

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