Where Birds Don't Fly

All roads lead to Rome and there are many different ways of reaching the same goal or objective. Finding the rootcause takes a road trip defining the turns and forks in the road. If travelling by air the course may take a detour by relying on the old ADF, or be more effective following a GPS course. There are several root cause analysis techniques and they all serve a purpose to improve safety and one rootcause model may be as effective, or ineffective as another. All rootcause analysis models are designed to establish at what time or location in the failed process a different approach could have made a different outcome. The 5-Why and fish bone rootcause analysis are widely accepted within the aviation industry and assumed to have established the correct rootcause. A risk assessment of substitute and residual risks is normally conducted after the rootcause analysis to identify if there are other or unexpected hazards by the implementation of proposed corrective action plan in the form

A small operator communicates differently with their personnel than how a mega-enterprise would communicate. An airport with 2 or 3 people, being an Airport Manager, SMS Manager and Accountable Executive may communicate verbally without much documentation, while a larger airport may use multiple levels of communications processes. Both operators must meet the same requirement of the expectation that communication processes (written, meetings, electronic, etc.) are commensurate with the size and complexity of the organization. When applying this expectation without ambiguity, or applying the expectation with fairness to the expectation itself, both operators are expected to apply the exact same processes in communication. The simplest avenue when assessing for regulatory compliance is to apply the more complex communication processes to both operators. When applying this approach, the smaller airport’s SMS becomes a bureaucratic, unprofessional and ineffective tool for safe operations.

Root cause analysis is to find the single cause of why an unplanned event happened, or a link in the process where a different decision would have made a different outcome. This does not necessarily imply that a different outcome would have avoided the unplanned event, but it may have happened at a different time or location and with a different outcome. The expectation of a different outcome is that the unplanned event would not happen. When analyzing for the root cause the 5-Why process is often applied. Unless there is an unbiased process applied to the answers of the 5-Why process, the desired answers could be established prior to initiating the process and the answers are tracked backtracked from this desired answer. The fact of this is that most 5-Why processes only allows for one option for the root cause. Since the organization is determined to establish a root cause, the root could be established without applying the 5-Why process. This is the “checkbox” syndrome of establishi