SofemaOnline takes a deep dive into Root Cause Analysis (RCA).

Introduction - What Do We Mean when we talk about "Root Cause"?

This is the first challenge and typically causes confusion across the business, with some people believing there is always a “single” root cause to a particular issue or problem.

In fact, as we will quickly see, there can indeed be multiple root causes associated with a single problem.

The purpose of the Root Cause Analysis is to understand the causal factors that contribute to a particular event.

Please consider the following definition:

A root cause is the deepest, most fundamental, earliest cause that led to a particular problem within a particular area - noting that multiple areas can conspire to create a problem - therefore we can indeed have multiple root causes for a given problem.

Any root cause should be both tangible and meaningful to the overall Root Cause Process. (Ideally, we should be able to address the root cause means to correct the anomaly in a way which provides a positive 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.

What is our interest in Root Cause?

We cannot afford to fix every problem we face - in fact, some problems we have to learn to live with and other problems we take action on, which provides a “partial solution.”

So we are looking for solutions that both deliver and also provide us with the optimum return on investment (ROI) and ideally to achieve a fix that provides a strong and positive solution that prevents re-occurrence.

 In our aviation systems, we are always going to need to get to the root cause of any problem or series of problems, with the best RCA being carefully mapped to consider all potential causes.

Typical Root Causes found in our Aviation Systems include the following:

▪ 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, of 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.

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