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.
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SMS was the key to the future, but no
one knew what was behind the locked door.
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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.
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Some trees failed to follow the
shedding leaves policy.
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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.
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The point of no return is the moment when
the first Why-door is opened.
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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
