What-When-Where-Why-Who & How
By OffRoadPilots
A safety management system (SMS) for airport and airlines is defined as a
documented process for managing risks that integrates operations and technical
systems with the management of financial and human resources. A quality
assurance program is an integrated part of a safety management system.
An integrated part to a safety
management system is when
different systems,
subsystems, or components
work together seamlessly to
perform specific tasks or
functions. Integration
involves combining software,
hardware, environment,
liveware (SHELL model), and
various technologies to
create a cohesive and
efficient system.
Integration is a crucial components of a quality assurance program when
performing root cause analyses and system analyses of special cause variations.
A root cause analysis is founded on answer provided by asking What question,
When question, Where question, Why question, Who question (group, or position
as opposed to an individual), and How question. These questions are
preestablished in processes in preparation for root cause and system analyses for
SMS enterprises to operate with a documented and businesslike system approach
to safety in operations. These questions are included in the processes to preserve
the integrity of their root cause analyses and the system analyses.The SHELL model, in the context of human factors and ergonomics, is a framework
used to understand and analyze the interaction between individuals and their work
environments, and is applied to enhance safety, efficiency, and overall human
performance.
The SHELL model consists of four key elements or layers, each representing a
different aspect of the work environment and its interaction with individuals:
Software (S): The software layer represents the organization's policies, procedures,
regulations, and the overall culture. It encompasses the rules and guidelines that
shape how work is done within an organization. Software influences how
individuals perceive their roles, responsibilities, and the expectations placed upon
them.
Hardware (H): The hardware layer includes physical elements such as equipment,
tools, machinery, and technology. It represents the tangible aspects of the work
environment that individuals interact with to perform their tasks. The design,
usability, and maintenance of hardware can greatly impact human performance
and safety.
Environment (E): The environment layer encompasses the external conditions in
which work is conducted. This includes factors such as lighting, noise, temperature,
and workspace layout. A conducive work environment contributes to the comfort,
well-being, and effectiveness of individuals.
Liveware (L): Liveware refers to the human elements of the system, including the
individuals themselves, their skills, knowledge, experience, physical and mental
capabilities, and interpersonal interactions. It recognizes that humans are not
passive recipients of their work environments but active participants who bring
their own strengths and limitations to the equation.
The SHELL model emphasizes the interplay and interdependencies between these
four layers. It recognizes that changes or issues in one layer can have ripple effectsthroughout the entire system. For example, a change in organizational policies
(Software) can impact how individuals perform their tasks using certain equipment
(Hardware) and influence their comfort and stress levels (Environment). The
Liveware layer is central to the model, as it is where the human operator interacts
with and adapts to the other layers.
By using the SHELL model, SMS enterprises can identify potential sources of error,
inefficiency, or safety risks within the work system and implement improvements
at multiple levels to enhance overall system performance and safety. This
approach is particularly valuable in safety-critical industries where human factors
have significant consequences.
A root cause analysis precedes
the What, When, Where,
Why, Who and How questions
by using a root cause analysis
tools and techniques. There
are several different tools and
techniques that can be used
for root cause analysis,
depending on the complexity of the problem and the specific context in which the analysis is being performed.
5 Whys: The 5 Whys technique involves asking "why" repeatedly (typically five
times) to drill down to the root cause of a problem. It is a simple yet effective
method to uncover deeper causes.
Fishbone Diagram (Ishikawa or Cause-and-Effect Diagram): This tool is used to
visualize and categorize potential causes of a problem. The main categories, or
"bones" of the fishbone, represent different factors, and subcategories break
down those factors into more specific causes.Fault Tree Analysis (FTA): FTA is a systematic, graphical method for analyzing the relationships between different events and their potential contributions to a problem.
It is commonly used in engineering and safety analysis.
Failure Modes and Effects Analysis (FMEA): FMEA is a proactive approach to
identifying potential failure modes in a system or process, assessing their severity,
likelihood, and detectability, and prioritizing them for corrective action.
Pareto Analysis: The Pareto Principle, also known as the 80/20 rule, suggests that
80% of problems are often caused by 20% of the factors. Pareto analysis helps
prioritize which issues or factors to address first.
Scatter Diagrams: Scatter diagrams are used to visually represent the relationship
between two variables. They can help identify potential correlations or patterns
that may be contributing to a problem.
Process Mapping: Process mapping involves creating a visual representation of a
process to identify bottlenecks, inefficiencies, or potential sources of problems.
Tools like flowcharts or Value Stream Maps (VSM) are commonly used for this
purpose.
Brainstorming: This is a creative technique where a group of individuals generates
a list of potential causes for a problem. It's a preliminary step often used in
combination with other analysis methods.
Control Charts: Control charts are used in statistical process control to monitor the
stability and performance of a process over time. Sudden variations or trends in
the data can be indicators of potential root causes.
Event Tree Analysis: Similar to fault tree analysis, event tree analysis is used to
analyze potential outcomes and causes of a specific event or incident.Barrier Analysis: Barrier analysis focuses on identifying the barriers that failed or
were missing in a system or process, leading to a problem. It's often used in safety
and risk management.
Change Analysis: This method assesses the impact of recent changes on a process
to determine if they are responsible for problems or issues.
Data Mining and Analytics: Advanced data analysis techniques, including statistical
analysis, machine learning, and data visualization, can be employed to uncover
root causes in large datasets.
The choice of which tool or method to use depends on the nature of the problem,
the resources available, and the expertise of the individuals conducting the
analysis. In many cases, a combination of these tools may be used to
comprehensively identify and address root causes.
After the root cause has been
determined, the next step is
to learn where in the system
the special cause variation
occurred by applying the 5-
Ws+how, and the impact
each answer had on human
factors, organizational
factors, supervision factors or
environmental factors. The
concept of the 5-Ws+how
could be applied to a kitchen
table and chairs. Both table and chairs are designed to be comfortable for an adult
but is not comfortable for a young child. This practice is widely accepted as a design and operational process. When a young child spills the milk-glass the child is blamed, and no changes are made. When applying the 5-Ws+how, one of these factors, human factors, organizational factors, supervision factors or
environmental factors, may have avoided the incident. Equally, each factor is
contributing 25%, but a root cause analysis may determine that environmental
factors contributed to 40%, and 20% to each of the other factors.
The corrective action plan became to design and develop a child-chair for a young child to sit on at the table. SMS for airports and airlines is not different than to design and
develop a system that is suitable for the condition and operational reliable.
The What question is about what occurred within each factor of human factors,
organizational factors, supervision factors or environmental factors. A root cause
analysis is like drilling a water well and to drill as far down as it takes until there is
fresh and clean drinking water. A weight score of the 5-Ws+how is assigned to
each factor.
A root cause consideration analysis is a tool where weight scores are entered. For a
root cause to be true there must be pre-established criteria. Should the root cause
be ineffective, these criteria need to be further analyzed for reliability.
Assign a weight score on a
scale from 1-2-3-4 to human
factors, organizational factors,
supervision factors and
environmental factors, where 1
is the lowest score, or the
factor which least impacted a
special cause variation, and 4 is
the factor which had the most
impact on a special cause
variation. Note that this weight score is not assigned to the occurrence, but to the
factors by predetermined considerations.
Enter weight scores 1,2,3,4 to human factors, organizational factors, supervision
factors or environmental factors for each one of the 5-Ws+how. Add up the weight
score and the highest score is the factor with the highest impact on a special causevariation. If two weight scores are of equal value, assign the weight score to the
highest Why-score in the analysis. The Why-score is selected as the primary factor
since the Why-score is more relevant to learning and improvements than the other
Ws & How.
When analysing the 5-Ws+how, make a target statement, or a root cause
statement. A root cause statement should be stated in one sentence.
A target statement, or root
cause statement is referred
to as a thesis statement
which typically is a one
sentence. A one sentence
statement demands that an
airport or airline operator
enter into the root cause
analysis at the correct
location.
Clarity: A one-sentence
target statement is concise and to the point, making it clear to the reader what the
main point or argument of the paper is. It eliminates ambiguity and ensures that
the reader can easily understand the focus of the paper.
Focus: A single sentence helps an accountable executive to maintain focus on the
central idea or argument of the root cause. It forces the accountable executive to
distill their main point into a single, clear statement, which can prevent the root
cause from becoming vague or wandering off-topic.
Organizational guide: A well-crafted thesis statement serves as a guide for the
structure and organization of a root cause. Each paragraph and section should
relate back to and support the thesis statement, making it easier to create a
coherent and logical argument.Reader's expectations: When a reader encounters a one-sentence thesis statement, they know what to expect from the rest of the analysis. It sets the
reader's expectations and helps them follow an argument more easily.
Argumentative strength: A strong thesis statement presents a clear and debatable
argument. This encourages critical thinking and discussion, making the analysis
more engaging and persuasive.
Revision and refinement: Having a single sentence as a thesis statement makes it
easier to review, revise, and refine the purpose. It serves as a clear reference
point, helping to evaluate whether the content of the analysis effectively supports
the main point.
While a one-sentence thesis statement is the norm, it's important to note that the
complexity and length of the statement may vary depending on the type of paper
and the depth of the argument. In some cases, particularly in longer and more
complex root cause, an accountable executive may have a more nuanced thesis
that requires a slightly longer statement. However, even in such cases, it should
still be concise and focused. A longer and complex root cause statement is a tool to
establish a pro forma document for the analysis to filter down to the true root
cause.
The secret to a successful Factor Analysis is to apply the 5-Why Root Cause
principle to the 5Ws+How. When the question is only asked once for each of the
5Ws+How, there will only be answer to each one of the factors and increasing the
probability of errors. An old saying is not to put all your eggs in one basket, and the
same hold true for a successful safety management system. The text in the
question may be the same, or similar, but changes are the What-When-Where-
Why-Who and How.
A "What" question typically seeks information or an explanation about a specific
thing, action, event, or concept. The answer to a "What" question will generallyprovide details, descriptions, or definitions related to the subject of the question.
The exact nature of the answer depends on the context of the question.
A "When" question typically seeks information about the timing, duration, or
frequency of an event or action. The answer to a "When" question usually includes
a specific time, date, period, or point in time. The format of the answer can vary
depending on the context and the specific question.
A "Where" question seeks information about the location or place of something or
someone. When a "Where" question is asked, a person is typically looking for a
specific location or destination as the answer.
A "Why" question typically seeks an explanation or reason for something and is
used in an interrogative sentence. An interrogative sentence is a sentence that
asks a question or makes a request for information. When the "why" question is
asked, it is essentially asking for the cause, purpose, or motivation behind a
particular event, action, or phenomenon. The answer to a "Why" question should
provide insight into the underlying factors or logic that led to the subject being
questioned.
A "Who" question is an interrogative question that seeks information about a group, entity, or
department. When a "Who" question is asked, they are typically looking for the identification of
the subject, group or department performing an action or having a particular characteristic. The answer to a "Who" question identifies the location in the process where a special cause variation was allowed to enter by a group, entity, or department.
A "How" question typically seeks an explanation or instruction about the method,
process, or steps involved in achieving a particular task or goal. When a "How"
question is asked, they are usually looking for information on the specific actions,
techniques, or procedures required to accomplish something. The answer to a
"How" question typically provides details, instructions, or a step-by-step guide to
help an accountable executive to understand a particular action to achieve a
particular outcome. The exact format and content of the answer will depend on
the specific "How" question asked.
Examples of answers to “How” questions.
The What-When-Where-Why-Who and How questions are designed to assist the
process to overcome, or defend itself, against future special cause variations.
The 5-Ws & How are needed for a processes to open the door to identify which
one of the four factors carry the most weight to be assigned the root cause
statement. The location of the root cause statement in the process is the location
where a special cause variations entered into a process. Unless these questions
and answers are preestablished and defining areas of opportunities for special
cause variations to enter the process, their system analyses teams are sent on a
wild goose chase when assigning root cause statements.
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