Root Cause Analysis

Root Cause Analysis

Post by CatalinaNJB

When the root cause of an accident is determined to be that a pilot failed to act on something, whatever this failure might be, the root cause analysis becomes a simple task of making that statement. The root cause could be assigned by management or by the pilot and accepted by management in their root cause analysis. A pilot may state that: “I inadvertently failed to meet the pilot-in-command requirements for a tailwheel airplane…” or a statement of: “The failure of the pilot to maintain adequate clearance with the terrain during aerobatic maneuvering.” Other root cause human error failure could be that: “The pilot failed to maintain clearance with a fuel truck and failed to request a marshaller and wingwalkers”.  With any of these root cause statements accepted by management, the root cause analysis is completed, the file is closed and put on the shelf with comments of “no further action required. “Assigning root cause of failure not to perform a specific task, or two, is acceptable practice in the aviation industry from an airport, to the smallest air operator, a major carrier or a freight operator. 

The root cause of a nonconformance, a logistics interruption, an unplanned event or an undesirable event is the course of action selected at a decision point, or when arriving at the fork in the road within a system.

There is a lot of talk about an SMS system, but nobody explains what it is. The regulator gives system findings but does not identify the system that failed. Well, they might say that the SMS system failed to conform to regulatory requirements, but that doesn’t explain what system failed. Operators make corrective actions to fix the system that the regulatory had identified as failed, but do not identify what system they are correcting. SMS is at the verge of falling apart, since there were no tangible goals to aim for after the SMS itself had been implemented. The only goal was to implement SMS and no there are no goals anymore. SMS has become a circle of opportunities. As we all know, travelling the circle of opportunities only lead to the same place as we were before. The SMS is lacking visions, goals and root cause guidance that makes a difference.   

SMS fell out of the sky since there was no visions after implementation.

A root cause cannot be assigned to a task that was not performed. E.g. the pilot failed to follow procedures. If this is the true root cause, the conversation ends here. It is not possible to make improvements to the task itself when it wasn’t performed. A better way to state the root cause would be for an operator to state that the pilot acted willfully when omitting procedures during aircraft operations. 

Now we are cooking… at least there are events to work with for the root cause. This root cause must include that it was done willfully, or we are back to the first scenario that the pilot failed to follow procedures. Now that it has been established that the pilot acted willfully, there is an opportunity to change this willful behavior. Often, this is managed by firing of the pilot, or placing the person on unpaid leave for a day, week, or two. At least the operator feels that they are doing the right thing when punishing someone who willfully caused an incident. The only thing for the operator has left to do is to write a letter to the pilot’s file, or cause of firing, that the pilot acted willfully when causing the incident. The only barrier to this letter is that most operators reject the option to make it official. 

So, if an operator rejects to publicly and officially state that a pilot acted willfully, there is no possible way to address this root cause by blaming the pilot. In addition, the operator must then also assess other areas of operations for willful behavior that could have caused this system failure.  There are no reasons to include any of the standard phrases of willful misconduct, reckless behavior, criminal intent or illegal substance use, since none of these are job performance criteria and are not performed as a part of a Safety Management System.  Job performance criteria within an SMS system are safety critical areas and safety critical functions. 

Assigning wrong root causes over time chips away a perfect Safety Management System

The only time when a true root cause analysis can be conducted, and a real corrective action produced, is when an operator accepts accountability and the fact that an omission of something is not a root cause. With acceptance of accountability, an operator needs to exit their endless travel in the circle of opportunities and make real system changes. A root cause must be assigned to the system and not to a process, procedure, practice or expectation. The simple reason for this is that systems that are built with inherent flaws do not improve by making changes on any level below the system level itself. E.g. If the system doesn’t require a risk management analysis, there is no tools available for the operator to comprehend a latent hazard in the process. 

Let’s for a make up a virtual scenario where the finding was that a pilot failed to follow procedure and hit a fuel truck when taxiing. This is a small operator, operating out of a small airport and with a designated parking sport for loading and unloading freight. One day there is an event with 400 arrivals at this airport that normally has 50 or fewer movements per day. This event would last for one week.  For this to work out for these new airport guests, the airplane is moved to the back and behind the hangars for all business jets to be parked in a preferred location.  The pilot of the must taxi behind a hangar, make a 90 turn and then taxi between a hangar and the business jets. The pilot has 7 FT clearance to business jets. For several days the pilot taxied this route without any issues. Then, one day a fuel truck is parked next to the hangar and the clearance is reduced to 2 FT. The pilot observes the parked fuel truck coming around the corner, but the left wing strikes it. An immediate response from the pilot is that it was pilot’s fault, with the same response from the operator. Problem solved… or maybe not. 

A root cause analysis would show that there was a system failure of the logistics system, in that several parties missed their opportunity to exercise their accountability to safety and to conduct their own safety risk assessment of the changes. The airport, operator, freight customer and fuel operator all assumed this to be normal operations and that mitigation would not be required.  Highways do a safer job than aviation, in that they mitigate the changes with traffic cones, speed and other accountable actions. The aviation industry has missed their opportunities of being accountable to safety. These missed opportunities were contributing factors to the incident. 

This logistics system includes the air operator safety office, accepting the taxi route without mitigation, the airport authority which had an incomplete assessment of the taxi route form the new parking area to ensure that their customers had taxi clearance, the airport authority provided incomplete communication to flight crew of business jets that there is a frequent use taxi route in front of parked aircraft, the marshaller of business jets for parking had incomplete training in marshalling business jets where to park for taxi clearance, the fuel vendor provided incomplete training to fuel truck operator where to park for taxi clearance and the system of the freight operator missed an opportunity to mitigate the back-alley parking and standard departure times for non-standard operating conditions with a longer and complex taxi route.  

It was the system itself that failed by established expectations of normal operations without mitigation or elimination of hazards with an abnormal. A root cause cannot be that a pilot failed to perform. A root cause is tagged to the system level for the parties involved to discover the facts and effects of abnormal taxi operations and to mitigate or eliminate these facts. Somewhere there is someone who owns that root cause. When there is a comprehension of the true root cause an operator can exit their travel in the circle of opportunities and discover the benefits of SMS with continuous improvement of return on investment. In addition, a causal effect of temperature was overlooked with the temperature in the cockpit being 100°F, or 38°C. 

CatalinaNJB