The origin of an occurrence travels through multiple stages until it is analysed as a root cause. When it comes to aviation safety, prevention of accidents and the Safety Management System (SMS), conventional wisdom is that there could be multiple root causes causing an occurrence. There might be multiple root causes, but there is only one primary root cause breaking away, leading the way to define the scope of the root cause analysis. The fist step in a root cause analysis is not to learn why an occurrence happened or why a latent hazard became an issue, but it is to assign the scope of the analysis to multiple root cause factors. One reason for assigning predetermined root cause factors is to work within a structured analysis system. SMS is also a businesslike approach to safety. The aviation industry put a safety management system in place as an extra layer of protection for incremental safety improvements. When conducting a root cause analysis outside of a structured system, the analysis is without directional control. When working outside of a structured systems, opportunities and failures are allowed to be introduced in the process to follow the path of least resistance with a guaranteed failure of a root cause analysis.
|A lightning strike is a symptom and not a root cause|
|A root cause analysis is not filed in SMS but is traveling on the trip|
It is crucial for the successful application of a root cause to know what a root cause is not. A root cause analysis is not perfect, it is not the magic wand of miracles for accidents never to happen again. A root cause is not a system where prescriptive expectations are applied as regulations. A root cause statement is not a one-size-fit-all model, a root cause is not a model where everything is grouped. A root cause analysis is not about emotions, wishes or dreams, but is an imperfect system applied to proactive processes. Working with an imperfect system opens millions of doors of opportunities for improvements, while a perfect system is ridged without justifications to be changed. We all know the saying “If it ain’t broke don’t fix it.”