Friday, August 23, 2019

Why The 5-Why Root Cause Analysis Does Not Work


Why The 5-Why Root Cause Analysis Does Not Work

By Catalina9


Airports initiated their first SMS phase-in implementation about 10 years ago and airline operators had started three years earlier. Over the years the Safety Management System has matured and operators, being airports or airlines, have improved drastically in skills and comprehension of SMS. During the infant stage of SMS, this new system was looked upon as the key to unlock the future, a world of safety and a system to reduce or even eliminate aviation accidents.

SMS was the key to the future, but no one knew what was behind the locked door.

SMS is a brilliant system built on a solid foundation of collecting data for analysis. It takes time to build the SMS and it was to be phased in. One of the first plans were to phase-in over a 3-year period. After reviews and consultations, it was decided to implement over a four-year period with one phase annually.  The very first item on the list was the gap-analysis. Everyone was scrambling to find what they had in their own organization as safety systems. Since this was a brand-new regulation and a never used before Safety Management System, operators did not realize that they would not have any parts of the SMS in place. However, their analysis went into overdrive to justify their current safety operational systems. It’s not that operators were unsafe, but they did not operate with a Safety Management System in compliance with the new regulations. Some operators may have understood this and submitted a gap-analysis that they were not in compliance but would become in compliance. This was the only fact and an acceptable way to approach the new regulations. Without acceptance of facts operators with help of safety inspectors was steering SMS into a dead-end valley.

SMS was built in a time when pilot error was the standard root cause answer and it was a time without a just culture. Back then, human errors were not tolerated and any mistake in the eyes of airline operations was cause for firing. Pilots could be fired for refusing to depart with ice on the aircraft or it was expected that they would manipulate their flight and duty time to support operations. Pilot were working 24 hours a day regularly, but still showing paperwork of compliance. Operators kept pilots on call or stand-by all day, but if there were no flight that day, it was demanded that pilots entered this day as a day off. When the regulator came around, an organization would keep the hard-working pilots at home. There was no need for root cause analysis, since it was predetermined to be pilot error, or human error. Life was simple back then

Some trees failed to follow the shedding leaves policy.

Then, one day SMS came around knocking on door, with major changes expected for airports and airline operations. Nobody could believe that everyone had to be accountable. With the new SMS, senior management itself were required to operate with a forward-looking accountability and the person in charge was the Accountable Executive. This major change caused an opposition to the concept of SMS. The safety inspectors themselves felt intimidated by the new SMS regulation and opposed it vividly. With this situation, and without comprehending SMS, both safety inspectors and operators reverted instantly to the prior system of assigning blame. One blame was assigned to the SMS phase-in system itself and that Quality Assurance System should have been implemented first, before any of the other phase-in requirements. Since QA is based on Quality Control and data collection, implementation the QA system as the first phase would become a QA system in place to analyze nonexistent data. Many of the SMS principles were rejected by both inspectors and operators. Several news articles and surveys did support that SMS had failed safety.

The point of no return is the moment when the first Why-door is opened.
One of the SMS principle accepted was the 5-Why Root Cause analysis. This was a system that both inspectors and operators were familiar with. There are several root cause analyses available for application within an SMS, but the 5-Why became the most popular since they could ask a question beginning with Why. Everything was back to normal when the Why-question could be asked and accepted by the SMS regulations. Why did you do this? Why did the wing strike that obstacle? Why did the runway edge lights not work? Why did the pilot not turn right? Why did the vehicle roll backwards towards an airplane? Millions of these Why-questions were asked.

Answers to these questions had one common denominator and is the single reason why the 5-Why is not a true root cause analysis. The answers to a Why-question must include a negative. A Why-question cannot be answered with a positive, or an action applied. The answers would state that a pilot did not take action to avoid, that airport personnel did not look, or in worst case scenario that a person failed to follow rules or policies. A positive answer with an action applied would lead the operator farther away from a root cause classification.

Let’s assume for a moment that there is a vehicle parked half-way into a garage. A person comes up to the garage door opening and closes the door on top of the vehicle. When asking Why-question in a positive way, answers could be that the person was closing the garage door to keep other cars outside. The next answer to a Why-question could be that the day was over, or that it was time to go home. Another answer could be that they were running late. None of these applied action answers get’s you even close to determine the root cause. The fist answers would most likely be that the person did not see the car and each subsequent answer must include a negative. It is not possible to establish a negative as a fact, simply because it did not happen. Since an event did not occur, there is no data to analyze. In addition, when asking the 5-Why questions, the question itself is biased with a predetermined position of the answer. The very first answer to a Why-question opens one of many doors, becomes the cornerstone of the root cause analysis and determines the final answer, no matter how many times it’s asked.

A simple root cause analysis should ask the question How? A How-question is unbiased, neutral to the event and provide data to be collected for quality control and eventually quality assurance.   

Catalina9

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