Introduction
So we have an Issue or a problem or an event or an outcome!
It does not really matter how we identify the nature of the issue – the point is that if we only address the symptoms, we are likely to see the underlying problem repeat or reoccur even multiple times and with additional costs.
If we can look below the surface at the fundamental causes, and to address the underlying system and process causes we should be able to make the issue go away completely and at the same time often bring financial benefits or savings to the organisation.
Considering Root Cause
We use the term Root Cause Analysis (RCA)
To describe the process or technique which we employ to help us understand why the problem occurred in the first place. We try to do this in a systematic way often using organisational tools to identify the origin of the problem using a step by step process which will allow us to understand.
How to determine what happened and following this to determine why it happened, in this way we will be able to take measures which will allow us to take steps “mitigations” which will reduce the likelihood that it will happen again.
We also assume a connectivity in respect that the system and events are interrelated.
It is not unusual to see that a change in behaviour, circumstances or events in one area or type of equipment, will directly or indirectly impact an action or event in another area. Often this connectivity will repeating and compound.
If we can unpick all this cause and event stuff we can hopefully get to the initiating event and to fix the issue once and for all.
Typical Causes
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 Quality Management System (QMS) and Safety Management System (SMS) for details please see www.sassofia.com or email: office@sassofia.com
