Understanding Complex Problems & Determination of Root Cause

Process Review by Sofema Online (www.sofemaonline.com)

Introduction

When investigating problems we should all aim to understand the difference between addressing the symptoms of a problem versus understanding the contributing factors and finally understanding the Root Causes of a given situation or problem.

If we can look deeper and to address on the way all Root Causes as well as Contributing Factors, then we can consider how to fix the underlying disconnects in the system and processes so that that the problem hopefully goes away and does not re-occur.

Root Cause Analysis (RCA) accepts that systems and events are often interconnected, by following a set of investigation rules we can discover not only how the problem started we can also understand all the associated elements and to take steps to fix the underlying issues.

Introducing Root Cause

Root Cause Analysis (RCA) techniques seek to uncover the origin of a problem using a specific set of “tools” with the objective of determining the why and what of the issue. (What happened & Why it happened.)
To assess the potential (likelihood for re-occurrence) and finally to understand how we can make the problem go away – Provide Mitigations (implement solutions).

Typically, we find 3 types of causes:

Physical causes or technical related, Human Factor/ People related, and Organizational related causes, for example- System, Processes also Policies which we use to make decisions in the workplace.

What does RCA do for us?

RCA looks at all causal elements and by investigating the various elements and influences including finding any “disconnects” in the system leading to the potential for developing all-round solutions

Note - It is often the case that RCA reveals multiple Root Causes.

The Root Cause Analysis Process in Simple Steps

1/ Problem Definition - Define the Problem What & How - Any other Symptoms

2/ Data Collection - Evidence related to the problem - Duration & Impact

3/ Identify Causal Factors - Sequence of Events and Pre-Cursor Conditions. Important to go as deep as possible to uncover as many factors as possible (Use RCA Tools at this stage)

4/ Now proceed to Identify the Root Cause(s) - Understand WHY the Causal Factors Exist & WHAT is the Fundamental / Real reason behind the problem (Test with RCA tools)

5/ Propose Solutions & Mitigations - Ownership & Process of implementation (Including Risk Assessment) Impact Assessment - Using Tools

Sofema Aviation Services and Sofema Online provide EASA Compliant Regulatory & Vocational Training including Quality & Safety Assurance and Root Cause Analysis Techniques. For more information please see the website or email: office@sassofia.com or online@sassofia.com