Root Cause

 Root Cause

By OffRoadPilots

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 needs  to be analysed in a 3D system measured in time  

(speed), space (location), and  compass (direction) and  within the scope of human factors, organizational factors, supervision factors  and environmental factors. A 3D analysis system places the environment of events. However, assigning and implementing changes to operations based on a root  cause analysis is not a guarantee that same or similar occurrences are eliminated in the future. 

This is a fundamental principle of an SMS and published by ICAO that  “Safety is not risk free.” An SMS regulation states that an SMS Enterprise needs a  process for the internal reporting and analyzing of hazards, incidents, and  accidents and for taking corrective actions to prevent their recurrence. Conforming  to this regulation does not guarantee elimination of future occurrences, but a  corrective action under the control of the enterprise that could have prevented  the non-compliance. The purpose of a root cause analysis is to predict with a 95%  confidence level the probability for a successful outcome without an unscheduled event. There are several more contributing factors beyond the control of an  operator than there are factors under their control.  

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.” 

A safety management system is about human behaviors and how external events affect internal emotions and human behaviors. This makes a root cause analysis  different from a root cause analysis of mechanical or tangible items. A root cause  analysis of material strength only needs one special cause variation, or one failure, 

to conduct a root cause analysis of its system. Material is reliable and when  produced the same way will provide the same output. Human factors are different,  that the same input, such as training and learning, does not provide the same  operational output between different people.  

A Non-Destructive Testing system (NDT) is a system to detect flaws within a  material or on its surface, and to established if production process produces flaws  or failures. There are different independent systems within an NDT system and  none of these systems are compatible to interact with the other systems. Some  frequently used NDT inspection process are X-ray, ultrasound, magnetic particle,  fluorescent penetrant, or acid inspections. The system of X-ray inspection is  applied to inspect for flaws within a material to relatively fine and defined  resolutions. Ultrasound is also applied to inspect for flaws within a material, but to  a relatively course and undefined resolutions. Magnetic particle inspection is  applied to both internal and external material flaws discovery. NDT inspection  system is applied to external inspection of flaws is the fluorescent penetrant  inspection. Acid inspection is a surface inspections of material temperature  variations. Within an NDT system all these independent systems function to  produce an outcome of an effective system that will function as it was designed to  function. None of these methods of NDT inspections are inferior to one or the  other, they are just a part of one total system to manage, or lead processes to  produce a flawless output. 

In the same way as an NDT system defines the scope of its intended inspection,  and the scope of a root cause analysis after a failure discovery, a root cause  analysis within a safety management system must also define its scope and root  cause analysis factor. In a material failure root cause analysis, the scope is  predefined and could be of the mixtures, the oven temperatures, the vacuum  chamber, the manufacturing process or the assembly process. Without defining  the scope, a root cause is only an opinion of the 5-Ws and How. A root cause  analysis within an SMS Enterprise establishes human factors, organizational  factors, supervision factors and environmental factors as their primary scope of  analysis. Several other factors could be added, such as mechanical factors, 

electronic factors, material factors, economical factors, ergometric factors and  more.  

Assume for a moment that there was a flaw in a compressor disk bult for extreme  high RPM. An undetected microscopic flaw could cause a major destruction to the compressor itself and equipment it was powering. When a flaw or material failure  is discovered the scope of the root cause must first be decided on. The root cause  could be of human factors, inspection processing factors, material composite  

factors or manufacturing factors. Each factor may have contributed to the flaw,  but only one factor would be the primary root cause for a corrective action plan.

Jumping to conclusion could end up in a crash

A root cause analysis within an SM Enterprise is prone to pre-analysis conclusions or jumping to conclusions without first determining the scope of analysis. When a root cause analysis is assigned to a responsible person, the first step is to ask the 5-why root cause is predetermined, the analysis question. When the first Why-questions demands a trail that leads to a predetermined answer. A root  cause analysis outcome may be affected by intimidation, or high-level management demanding root cause to be identified as human errors. Should an  SMS manager oppose their demand to jump to the human error conclusion, senior  managers may become verbally abusive and feeling ignored, that their opinions  are not important, and find it shocking that their SMS manager is running a  program that nobody have control over. This is a virtual scenario, but with a  probable likelihood to occur. A root cause analysis needs to first establish the  scope to remain neutral.  

The first purpose of a root cause analysis is to identify system level findings non compliances that show a system-wide deficiency of an enterprise system. Examples of system findings are safety management system, quality assurance  program, operational control system, maintenance control system, or a training  program system.  

The second purpose of a root cause analysis is to identify process level findings of  an enterprise process which did not function and resulted in non-scheduled  output. Examples of processes applicable in various aviation industry sectors  include, but could be documentation control process, safety risk management  process, internal audit process, or emergency response testing processes.  

When a root cause analysis has established its scope and purpose, corrective  action assigned has an opportunity to successfully prevent further occurrences.  

OffRoadPilots

SMS Focus Group

 SMS Focus Group

By OffRoadPilots

A Safety Management System (SMS) Focus Group is a place with ongoing learning activities, assessments or events, virtual event discussion, or anything else in safety one can think of. Focus groups discussions tend to capture deep and more personal responses from consumers rather than purely quantifiable data. Focus groups can assist with identifying and analyzing hazards identified in the risk assessment process. An SMS focus group works well for consulting with workers and enable the collection of meaningful data on perceptions of their work environment. Some of the reasons for a focus group are to obtain more detailed information and insights into the importance of hazards, to better understand opinions and issues regarding the work environment, to establish a safe and open environment, or just culture, to express views, to provide a broad representation of diverse ideas and experiences on safety assurance topics, and to generate strategies and solutions for addressing hazards. A focus group may be closed and only available to members, or it could be an open focus group with transparency within a just culture. 

There are several responsibilities for the person managing the safety management system (SMS Manager). Two of the responsibilities of an SMS manager is to determine the adequacy of the training for personnel, and to monitor the concerns of the civil aviation industry in respect of safety and their perceived effect on the holder. Both responsibilities are achieved through SMS focus groups and acceptance of accountability. An SMS manager is accountable to the Accountable Executive (AE) and their conformance to regulatory requirements paints a picture of how well the AE perform their duties to be responsible for operations and their accountability level on behalf of the certificate holder for meeting the requirements of the regulations. 

Pre-SMS accountability was to hold someone accountable, or to find someone to point the finger at, and then punish that person. This old-fashion accountability principle was based on a concept that all systems were fail-free, that any system could not fail, and the reason for failure was simply that personnel deliberately ignored their tasks. A person causing an incident was considered to a bad apple within the organization. What was forgotten was that bad apples are bad because of their treatment, or lack thereof. The simplest way for a manger to identify bad apples, is to walk up to a mirror and take a close look at the person responsible. Imagine there is a box of apples in an uncontrolled environment, where the temperature varies with the day and night temperature. When you open the box, there are one or two bad apples on top. This is your root cause. In your opinion the root cause was these two bad apples, and the apples are removed. A week later you open the box again and there are several more bad apples in the box. This goes on for weeks and apple after apple are fired, or removed, until the box is empty. When all bad apples are gone the goal not to have any bad apples within the organization is reached. What was forgotten, was that these apples became bad because their treatment, or lack of treatment, and were not given proper treatment prior to be placed in the box. Apples are sensitive creatures, just as the human mind is a delicate operations system. When apples are picked, they must carefully be placed into the box, and the box must be placed in a temperature-controlled environment. Bad apples happens when an organization does not comprehend the system. 

Accountability is to bring solutions to problems, as opposed to complain and do nothing about it. As example, if a copier is not working, call the mechanic to repair it instead of complaining that it’s not working. Action demonstrates leadership and shows accountability. Accountability is to be proactive and do tasks required to meet a goal. Accountability is demonstrated by taking charge and being proactive. This does not imply that accountability is to do some one else’s job, or take on tasks beyond knowledge or capability, but it is to accept responsibility to initiate an action to solve a problem or remove a hazard. Submitting an SMS report could be the only action needed. However, if the hazard was Foreign Object Debris (FOD) on the ramp, then remove the FOD prior to submitting the report. Accountability is forward looking accountability. Imagine, if in the year 1857 you told the transportation experts that carriages will be travelling at 80 miles per hour in opposite direction and separated by only a painted line. Nobody would believe it could happen, because horses could not travel 80 MPH, even if 300 horsepowers were placed in front of the carriage. At a minimum, transportation experts would expect the carriages to be separated by a stone wall, or wooden fence. But 150 years later vehicles are travelling at 80 MPH only separated by a painted yellow line and the system works because of forward looking accountability. When backwards looking accountability is applied, harm has already occurred, and the past cannot be changed.  

 

Speaking up about problem areas is accountability and helps bring teams together to find solutions. A person who brings constructive criticism and solutions to the table shows character, personality, and leadership skills. One of the most difficult tasks of accountability is to admit personal mistakes and misjudgments, or to be included in an action which was a contributing cause to an incident. Accountability is taking ownership of actions and actions of the team supervised. If you made a mistake, admit to it and learn from it. Moreover, when mistakes are accepted, several doors open up with multiple paths for solutions. Accountability is to accept criticism. As a manager, if a team member tells you that goals don’t make sense, listen, and implement the goal-setting process. Another great example of accountability is to stay focused on achieving goals and tasks. Communication is another key to accountability in the workplace. Communication helps to establish goals and accomplish them efficiently.  Accountability is to communicate calmly, clearly, and patiently, and despite disagreements, demonstrate maturity and is a great example of accountability. Showing up is one of the greatest examples of accountability in the workplace. Suppose you don’t have any task to do as a leader. However, your team has several tasks to do to ensure the goal is met. If you’re not present on the floor to lead, you are not being accountable.

 

There are several benefits of accountability, from increasing collaboration, promotes performance, higher returns for a business, foster trustworthiness, cooperation, and responsibility. It ensures effective communication. Accountability makes achieving goals easier, ensures cohesiveness and enables the team to take on more responsibility. Accountability is also an ingredient of a just culture, where there is trust – learning – accountability and information sharing.  

 

An SMS focus group foster accountability, generates trust, instill learning, and is an information sharing tool. Activities in an SMS focus group is ongoing, at a minimum with a new task or problem presented monthly. In a large organization, SMS focus groups should be assigned into functional areas of operations. In a smaller organization, everyone in the group is assigned the same task. 

 

An SMS focus group task might be to analyze comprehensive statements such as the statement below: 

 

“An SMS is an explicit, comprehensive, and proactive process for managing risks that integrates operations and technical systems with financial and human resource management, for all activities related to operations, maintenance and flight following.

 

Practically speaking, a SMS is a business-like approach to safety. In keeping with all management systems, a SMS provides for goal setting, planning, and measuring performance. It concerns itself with organizational safety rather than the conventional health and safety at work concerns. An organization's SMS defines how it intends the management of air safety to be conducted as an integral part of their business management activities. A SMS is woven into the fabric of an organization. It becomes part of the culture; the way people do their jobs.

 

The organizational structures and activities that make up a SMS are found throughout an organization. Every employee in every department contributes to the safety health of the organization. In some departments safety management activity will be more visible than in others, but the system must be integrated into «the way things are done» throughout the establishment. This will be achieved by the implementation and continuing support of a safety program based on a coherent policy, that leads to well designed procedures.” 

 

An SMS focus group is an approach to conform to regulatory compliance. The approach might be to analyze a comprehensive statement, or a simple analysis of an identified hazard. An SMS focus group is a process to think outside the box, to comprehend the safety management system of an SMS enterprise and opens the doors for unlimited opportunities in aviation safety.

 

 

OffRoadPilots