Aviation SMS Root Cause Analysis – Ensuring Practitioner Competence

Sofema Aviation Services (www.sassofia.com) looks at effective management of competence related to Root Cause Analysis (RCA).


With RCA we are able to analyse and understand the precursors of a problem (symptom) and in this way address the cause rather than the effect leading to more permanent solutions.

It is essential for an organisation to engage effectively to fully address both RCA as well as all related contributing factors. To deliver this in the most optimum way requires the organisation to identify RCA competence as an organisations “Core Competence”.

Without a doubt, the organisation will benefit if we can identify and develop the necessary skills associated with root cause analysis.

Delivering Effective SMS Root Cause – Considering the Optimum “Learning Path”

Developing an efficient and effective process and behaviours in the organisation is essential if we are going to minimise our exposure to risk and improve the resilience of the organisation.

Whilst RCA techniques and behaviours may be taught in a systematic and logical way, this does not automatically mean that the Practitioner (Manager / Business Area Owner) will be able to perform in a consistent and reliable way.

One of the problems encountered is the tendency to jump to conclusions as to the cause of a particular problem rather than working through the due diligence processes which will explore and ultimately expose the fundamental root.

Mentoring for Effective RCA Technique Success

A process which involves “hands-on” mentored skill transfer needs to be introduced which will ensure that all persons meet a standard which is set within the organisation and in this way we can achieve an organisational approach to delivering reliable RCA assessment.

We should consider as part of our mentoring process what we expect as “good” behaviour and what may be considered as behaviour which “falls short” of expectations. In addition to accepting that there are different levels or depth of investigation from routine procedural related to an event which has caused greet stress or the loss of revenue to the organisation.

Preforming Logical Analysis

When we understand the true nature of the underlying, root cause we can start to develop effective mitigations, understanding the root causes (and note that often there are multiple root causes) can be addressed using basic analysis methodology.

Related to Physical Causes – This is when there is a specific failure of the infrastructure, or a mechanical mechanism – So we can clearly see that we have a failure – but this is only the very beginning of the story – the next question off course being to ask why?

Related to the Human Interface Causes – This considers the possibility of human error – many events involve various human errors which needs to be explored to understand the precursors as for sure it is highly likely that it was not intentional.

Related to Organizational Causes – When considering this aspect we are looking at failures in some way in the system, process, or even the underlying policies that are used to drive the decision-making process.

Sofema Aviation Services (SAS) is pleased to offer a range of EASA compliant regulatory training courses in support of Aviation Safety Management System (SMS) Hazard Identification, Risk Assessment, Root Cause Analysis & Mitigation Implementation. For details please see www.sassofia.com or email: office@sassofia.com.