WHY are Some Accident Recurring?

Why are some accident recurring?

 In our aviation culture we are great at Analyzing Failure. Our focus seems to be on “What happened.” Even with this great emphasis on Failure Analysis, we still see the recurrence of similar accidents. The question is why! I recently participated in a discussion on the Aviation Safety Group. The discussion brought up several reasons for the recurrence of some accidents. Here they are:

1. No resources to complete the job. Once a cause or causes have been identified, upper management does not support the efforts to implement the action necessary to eliminate or mitigate the causes. It seems that all Safety related issues can be traced back to upper management. Dr. W. Edwards Deming would not even work with a company in improving it’s quality unless the CEO on down were actively supporting the system.
2. Investigation team with no experience. I always push the idea that Root Cause Analysis, RCA,  teams must be “multidisciplinary.” In addition, there must be some experience members that have participated in other RCA sessions. No all the members of the team need to be experience but, there should be some facilitators that can lead the progress of the RCA.
3. Solutions do not reduce the risk in fact. This occurs when the RCA team goes in the wrong direction. It is important to utilize tools for Root Cause Analysis that take away the “type A” personality and gives each member of the team equal say. I have found that these tools are readily available and I recommend a booklet: “SMS Memory Jogger II” published by GOAL/QPC. There are many tools found in this book that will accomplish the equitable results of a RCA. (SMS Memory Jogger II can be found at dtitraining.com)

Tool book authored by Dennis and Sol Taboada

4. Failure on management recommendations. Remember that the person who knows         the most about a job is the person that actually does it. Management can recommend but, the recommendation must be analyzed and in most cases a risk assessment done to see if the recommendation itself does not add to the risk. 

5. The root causes are not identified. Of course this is the most popular answer as to why accidents recur. It is important to follow the procedures for a standard RCA tool. First we must know the tools and how to use them. If we do not address the real Root Cause(s), the problem will recur. 

It is important to educate yourself and your key employees on how to, first pick the right tool for the job, and then know how to use it. I have found symposiums to be an excellent forum to discuss, identify and use different tools to help manage risk, failure, RCA and goals for our company. There is an excellent symposium that I recommend coming up this September. “The TOOLS for SMS and QA.” This symposium will be held at the Coronado Resort on the Walt Disney World property in Orlando Florida..a beautiful location to bring the family!! Speakers will be excellent and the work shops very engaging and guaranteed to arm you with tools that will enhance your companies Management Systems, both QA and SMS. You can learn about the symposium by going to my website: dtitraining.com  click on symposium or go to the GOAL/QPC website:  goalqpc.com/dti  

Your thoughts.....