What Do Business Leaders, Executives and Senior Managers Need to Know About Direct Cause, Root Cause & Contributing Factors

Sofema Aviation Services (www.sassofia.com) considers the various factors associated with Root Cause Analysis (RCA) and how to embrace the opportunities presented to drive improvements and efficiencies.

Introduction

Q - What is Root Cause?

A - In essence, It is the process of understanding what went wrong & why it does not fix anything simply it aids understanding.

Q - So what is a Contributing Factor?

A - So when we work towards understanding the deepest cause of an “event” we come up against a number of “pre-cursors” or contributing factors – simply put this happened because of “A” and  “A” happened because of “B”  - each time going a little deeper until we pretty well reach the end of the story (from a practical perspective) – Although we can usually go deeper, but we are too far away from the event.

Q – And Direct Cause

A - Sure this is the actual “something” that led to the situation we are in now!

Common Misconceptions

We commit an error when we look at RCA as not only the cause but also the solution – which means if we do the opposite of whatever we decide is the RC then we are good – Off Course it does not work like this.

We need to ideally develop a “change” in behavior or process (let's call it mitigation) for each & every contributing factor we identify.

What do we Find when we perform RCA?

Note that it is possible that the Root Cause at the lowest level becomes a disconnect where the issue we have now identified and are considering  is actually an aspect of the management system which has failed to identify this “Issue” as a

“system exposure”

Consider:

·    Lack of preventative measures can influence the event we are trying to examine
·    Organisational Culture and Well Being Issues impacting Effectiveness of RCA Activities
·    Identifying a training need, lack of leadership or management is typically not the root causes. (Yes, agreed they are contributing causes – but the “Root Cause” will be found deeper within the Management System Controls)

Tools to Work with Root Cause

It is highly important to focus on “Return on Investment” regarding any analytical activities undertaken. Whether we choose the following or go with a full “Bow Tie” analysis depends on circumstances related to the magnitude of the issue and the hurt which is being felt.

·    Simple 5 Why – Quick and Effective to a point – But tends to focus on the outcome and miss some of the contributors
·    Ishikawa Fishbone – Good for exposing Multiple Pre-cursors and can be used in conjunction with 5 Why
·    Pareto Analysis – Based on the notion that 80% of what goes wrong is caused by 20% of the story – If we turn it around we can improve 80% of an issue with 20% of the effort

Next Step

Please take a look at this course which is designed for Senior Managers

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