What-When-Where-Why-Who & How

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 effects throughout 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 cause variation. 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.

Preestablished considerations when applying the 5-Ws and how
	HUMAN FACTORS	ORGANIZATIONAL FACTORS	SUPERVISION FACTORS	ENVIRONMENTAL FACTORS
WHAT	Human behavior, performance, and reaction to event.	A framework to outline authority, accountability, roles responsibilities, and communication processes.	Function of leading, coordinating, and the work of others to accomplish the objective. This also include the accountable executive.	Design and performance environment of design applicability for job performance and encouraging engagement or disengagement in task-result oriented activities.
WHEN	Airport and airline safety processes and decision-making.	Design of processes and application of processes in the operational environment	Hourly or daily within scheduled or on-demand working hours of personnel with result-oriented applications.	Hourly or daily within scheduled or on-demand working hours of personnel at the airfield for airport personnel, or while on-duty for flight crew. All aspects of airport operations, and flight operations.
WHERE	Airport and airline operations within operational management personnel.	Management policies, work culture, and operational processes.	Organizational management in a hierarchy of organizational structure.	All aspects of airport operations, or flight operations.
WHY	Human factors knowledge is used to optimize the fit between people and the systems in which they work to improve safety and performance.	Establish an organizational culture for operational processes, expectations, and acceptable work practices of level of safe operations.	Establishing authority, accountability, roles and decision authority within the operational processes.	Establishing and maintain an environment where personnel have access to design tools and encouragement for performance engagement.
WHO (group or position)	Anyone who have operational or SMS roles and responsibilities in airport operations, and airline operations, or management when designing SMS operational processes.	Establish, maintain, communicated, by airport managers, or flight operations managers, the person managing the safety management system on behalf of the accountable executive.	The accountable executive is responsible for operations and activities on behalf of the certificate holder. Other managers and supervisors, and the person managing the safety management system are responsible for operations and activities on behalf of the accountable executive.	Applicable to all personnel where the accountable executive is the final authority in the decision-making process with respect to the SMS policy, non-punitive policy, and objectives for safety in operations.
HOW	Application of processes and tasks for both reactive management and proactive management.	Delivery of structured processes within airport operations and airline operations.	Processes within the basic types of supervision. General types of supervision and leaders are: Structural, Participative, Servant-leader, Freedom-thinking and Transformational-leader.	The final authority and decision-maker for design of safety operational systems is the accountable executive and implemented by Functional area Mangers, or the person managing the safety management system.

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 generally provide details, descriptions, or definitions related to the subject of the question. The exact nature of the answer depends on the context of the question.

Examples of answers to “What” questions.

	Human Factors	Human Factors	Human Factors	Human Factors	Human Factors
WHAT	What is the performance expectation for the task	What odor triggered a reaction	What view triggered a reaction	What prior training led to the reaction	What SMS policy statement led to the reaction

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.

Examples of answers to “When” questions.

	Human Factors	Human Factors	Human Factors	Human Factors	Human Factors
WHEN	When is the performance expectation for the task expected to happen	When does an odor trigger a reaction	When does a view trigger a reaction	When was training associated with special cause variations	When was an SMS policy integrated in operational processes

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. 

Examples of answers to “Where” questions. 

	Human Factors	Human Factors	Human Factors	Human Factors	Human Factors
WHERE	Where in the performance expectation did the special cause variation occur	Where in the process did an odor occur	Where in the process did a view occur	Where in the training process did a special cause variation enter	Where was an SMS policy integrated in operational processes

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.

Examples of answers to “Why” questions. 

	Human Factors	Human Factors	Human Factors	Human Factors	Human Factors
WHY	Why did an expectation open the door for a special cause variation occur	Why did the process allow for an odor to enter into the process	Why did the process allow for a view to enter into the process	Why did the training allow for a special cause variation to enter	Why did the SMS policy allow for a special cause variation to interrupt the process

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. 

Examples of answers to “Who” questions.

	Human Factors	Human Factors	Human Factors	Human Factors	Human Factors
WHO (group or position)	Who designed an expectation to open the door for a special cause variation occur	Who designed the process allowing for an odor to enter to enter into the process	Who designed the process allowing for a view to enter to enter into the process	Who designed the training program to allow for a special cause variation to enter	Who wrote the SMS policy to allow for a special cause variation to interrupt a process

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.

	Human Factors	Human Factors	Human Factors	Human Factors	Human Factors
HOW	How did an expectation open the door for a special cause variation occur	How did the process allow for an odor to enter into the process	How did the process allow for a view to enter into the process	How did training allow for a special cause variation to enter	How did the SMS policy allow for a special cause variation to interrupt the process

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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