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.

Steve Bentley CEO of Sofema Group (www.sassofia.com www.sofemaonline.com www.aets-sofema.com) considers the common errors that people make when considering Aviation Errors

Lack of Detail of Appreciation Related to the initial assessment of the Event, Issue or Problem

Spending time to analyze the initial problem so that we understand “What” has happened as well as “How” it happened. It is important to perform this analysis before moving onto Root Cause Analysis.

This will not only determine the nature of the problem but will also identify exactly where the problem exists within the system, to understand when it exists. So, it is important to recognize that a well defined Problem Statement drives the entire Root Cause Analysis effort.

Sofema Aviation Services (www.sassofia.com) considers key aspects related to Safety Management System (SMS) Root Cause processes.

Introduction

To fully engage with the RCA process and achieve effective risk analysis and assessment, requires that we first identify a process by which we can identify and report on hazards. 

SofemaOnline (www.sofemaonline.com) considers SMS RCA Obligations

Introduction

All elements of your business should share the same SMS as well as the same process of engagement, in addition, all elements and processes need to be promoted and educated throughout the organization.

The transition from a traditional SMS to the ICAO Annex 19 “Risk Managed Model”, required many changes throughout the organization process and procedures as well as physical within the workplace.

SofemaOnline takes a deep dive into Root Cause Analysis (RCA)

Introduction - What Do We Mean when we talk about "Root Cause"?

This is the first challenge and typically causes must confusion across the business with some people believing there is always a “single” root cause to a particular issue or problem.

In fact, as we will quickly see there can indeed be multiple root causes associated with a single problem.

The purpose of the Root Cause Analysis is to understand the causal factors that contribute to a particular event.

Reality Check! 

RCA should be conducted at a point where informed conclusions can be made, and realistic action plans formulated. In this way the process has the potential to drive real change in the short, medium and longer term.

SofemaOnline (www.sofemaonline.com) looks at the Root Cause Analysis (RCA) process

Introduction

Is RCA used for negative or positive purposes? In fact, often it is used in connection with negative reviews – means something has gone wrong and we are attempting to get to the bottom of it!

RCA can also be useful as a means to identify and promote positive outcomes and aspects which may not necessarily be a “finding” but which are however identified as an “opportunity” during specific audits.

Analytical Techniques (RCA Tools)

“Five Whys” Approach

The “five whys” approach. By using this approach, root cause contributors can be identified along with the antecedent events, and potential mitigation or prevention strategies can be suggested on the basis of the answers.

Once the initiating problem is specified, a consecutive series of “why” questions are asked, with each answer becoming the subject of the next question.

Note that with each response, not only does a deeper investigational dive occur, but opportunities for implementing mitigation strategies are highlighted.

Ishikawa Fishbone Diagrams

A fishbone diagram, which is essentially a cause and effect diagram provides for a graphic representation which categorises the potential causes related to a problem in order to identify the root causes.