Organizations must move beyond compliance-driven responses and embrace a culture of critical thinking and continual improvement.
• This requires investment in training, process reinforcement, and leadership commitment to embed RCA into the organizational DNA. Only then will findings be closed not just on paper, but in practice—enhancing both compliance and safety.
Often, auditees—particularly business area owners and nominated post holders—struggle to deliver meaningful and systemic root causes. Instead, they may provide symptoms, superficial causes, or vague responses that do not enable effective corrective and preventive actions.
Lack of Analytical Training
Many post holders and area managers are subject matter experts in their technical field (e.g., maintenance, operations or airworthiness management) but lack formal training in investigative and analytical techniques.
• Consequently, their approach to RCA is often intuitive and based on experience, rather than structured and evidence-based.
There is frequently a culture of blame avoidance or fear of exposing systemic weaknesses. This can lead to:
• Defensive posturing during audits.
• Minimization of issues.
• Blame attribution to individuals rather than systemic contributors.
RCA is sometimes treated as a bureaucratic requirement rather than a genuine opportunity to improve safety and compliance.
• Business owners may view it as “tick-box” compliance rather than a critical thinking process.
Important Note Human Factors cannot ever be a Root Cause – Do you agree?
RCA requires time for thorough investigation, consultation, and documentation.
• In high-demand operational environments, staff may rush the process to close findings quickly, leading to shallow or incomplete analysis.
Auditees often confuse contributing factors (e.g., staff shortages, workload, lack of communication) with root causes. While these are important, they do not answer the fundamental “why” behind the occurrence.
Implement formal training based on proven models like:
• The “5 Whys” Method
• Ishikawa (Fishbone) Diagrams
• Failure Mode and Effects Analysis (FMEA)
This training should be tailored to reflect the operational context of CAMO and AMO environments.
Encourage openness without fear of reprisal. Reinforce the concept that understanding mistakes leads to improvement, not punishment.
Use cross-functional RCA teams led by a neutral facilitator trained in investigation techniques. This helps overcome biases and ensures broader perspectives are considered.
Ensure RCA results feed into the Safety Management System (SMS) and Continuous Improvement initiatives. Encourage proactive identification of systemic deficiencies.
Auditors or quality managers should periodically review previously closed findings to assess the robustness of the RCA and the sustainability of corrective actions.
Example 1: Missed ARC Recommendation Due to Incomplete Work Package Review
• Issue: CAMO failed to include a critical Airworthiness Directive (AD) during the ARC review.
• Symptom: AD not listed in the work package.
• Shallow Cause: Engineer forgot to add the AD.
• True Root Cause: Ineffective procedures for validation of AD status during the preparation of ARC packages.
• Improvement: Implement a checklist-based verification process; update procedure to require dual review.
Example 2: Late Maintenance Planning
• Issue: Scheduled tasks were not planned in advance, causing operational disruptions.
• Symptom: Task list was delayed.
• True Root Cause: CAMO software not configured to generate alerts for upcoming tasks beyond a 30-day horizon.
• Improvement: Reconfigure system parameters; introduce a rolling 90-day task forecast review process.
Example 1: Tool Calibration Expired
• Issue: Use of a torque wrench with an expired calibration date.
• Symptom: QA audit found an expired sticker.
• True Root Cause: Calibration tracking system not linked to stores issuance, allowing tools to be used even when out of calibration.
• Improvement: Integrate tooling system with calibration alerts; staff training on tool control accountability.
Example 2: Repeated Finding for Incorrect CRS Completion
• Issue: CRS (Certificate of Release to Service) consistently had missing or incorrect data.
• Symptom: Incomplete release documents.
• True Root Cause: Inadequate training on completing EASA Form 1 and lack of standardized guidance.
• Improvement: Refresher training for certifying staff; visual work instructions posted in line station areas; CRS audit checklist introduced.
Sofema Aviation Services & Sofema Online provides Classroom, Webinar & Online EASA Compliant Regulatory Training – Please see the website or email team@sassofia.com.
