Root Cause Tutorial

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Root Cause Tutorial
2013
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More on Hazard Identification Techniques
One example of a system to proactively identify
hazards is to establish groups to identify safety
hazards by following five simple steps

1. Identify potential hazards that could threaten
   the safety of your employees, customers,
   passengers, company facilities, company assets,
   customer property.
2. Rank the severity of hazards.
3. Identify current control measures.
4. Evaluate the effectiveness of each control
   measure.
5. Identify additional control measures.

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Hazard Identification Program Assess Rank
Assess The Risk

• Critically assess the risk associated with the
  hazard.
• Factors to consider are the likelihood of the
  occurrence and the severity of the consequences.

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Hazard Identification Program Hazard Controls
Identify The Hazard Control

• Once the hazards are identified and the
  associated risk approximately ranked, hazard
  controls should be identified. The following
  illustrate how a hazard can be controlled.
• To prevent an unoccupied vehicle from rolling
  into an aircraft Require all vehicles to be
  chocked, with the parking brake applied and in
  placed in Park.
• To prevent a fire at the fuel farm No Smoking
  signs, routine inspections for electrical
  connections, leaks and debris, an effective foam
  suppression system, an emergency shutoff system,
  fire extinguisher, etc.
• Hazards identified at a particular airport
  Ensure that operating procedures are properly
  documented and implemented.

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Hazard Identification Program
Evaluate The Hazard Controls

• The appropriateness of the hazard control should
  be assessed.
• How effective is the hazard control?
• Does it prevent the occurrence (e.g., does it
  remove the hazard and eliminate or minimize the
  risk), or does it minimize the likelihood or the
  consequence?
• A control, once implemented, must be evaluated to
  ensure it minimizes the hazard and likelihood of
  occurrence.
• Example Fire extinguishers are placed onboard an
  aircraft. Is the crew trained on their use and
  are the fire extinguishers properly maintained?

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Hazard Identification Program
Identify the need for hazard elimination,
avoidance, or for further controls.

• Each hazard and its control(s) should be
  critically examined to determine whether the
  associated risk is appropriately managed or
  controlled.
• If it is, the operation may continue.
• If not, improve the hazard control, or remove or
  avoid the hazard.
• In some instances, a range of solutions to a risk
  may be available.
• Some may be engineering solutions (e.g.,
  redesign), which are generally the most
  effective, but can be expensive.
• Others involve control (e.g., operating
  procedures) and personnel (e.g., training) and
  may be less costly. A balance must be found
  between the cost and practicality of the various
  solutions.

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Safety Risk Management Safety Assurance Process
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Root Cause Analysis Introduction
Fatigue origin of the failed tail rotor drive
shaft coupling
ROOT CAUSE
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Root Cause Analysis
Root Cause The most basic reason for an
undesirable condition or problem which, if
eliminated or corrected, would have prevented it
from existing or occurring.Wilson, Dell, and
Anderson (1993), Root Cause Analysis.
Decision-Makers
Line Management
Organizational Preconditions, i.e., Company
Culture
Line Activities
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Root Cause Analysis
Wilson, Dell, and Anderson (1993), Root Cause
Analysis.
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Root Cause Analysis

• There are many analytical methods and tools
  available for determining root causes to unwanted
  occurrences and problems.

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Root Cause Analysis
Useful Tools for Determining Root Cause

• The 5 Whys Model
• Fishbone Diagrams
• Failure Modes Effects Analysis (FMEA)
• TapRooT Analysis

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Root Cause Analysis
Suggested Tools

• For efficiency and ease of use, we will discuss
• 5 Whys
• Fishbone Method

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Root Cause Analysis
The 5 Whys

• 1. As a group, write down the problem and
  describe it completely.
• 2. Ask why the problem occurs and write down the
  answer.
• 3. If the answer you just provided doesn't
  identify the root cause of the problem that you
  documented in step 1, ask why again and write
  that answer down.
• 4. Return to step 3 until the team is in
  agreement that the problem's root cause has been
  identified.
• This process may take fewer or more than five
  whys.

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Root Cause Analysis 5 Why Example

• Event You are operating a tug that is towing a
  Gulfstream IV. Suddenly, the tug becomes
  uncontrollable, which causes the tow hitch to
  break and extensive damage to the aircraft nose
  gear results.
• 1. Why did the aircraft become damaged?  
  - Because the tow bar hit the aircraft.
• 2. Why did the tow bar hit the aircraft?  
  - Because the tow hitch broke.
• 3. Why did the tow hitch break?   - Because
  the tug was uncontrollable.

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Root Cause Analysis 5 Why Example

• 4. Why did the tug become uncontrollable?  
  - Because the aircraft was being pulled with a
  tug rated below 10K draw bar pull.
• 5. Why was a tug with a rating that was below
  minimum being used ? - Because the tug
  operator was unaware of the guidance.
• 6. Why wasnt the tug operator aware of the
  guidance? - Because the tug operator was new and
  had not been trained on the guidance. - Because
  the operator was unaware of the guidance.
• 7. Why hadnt the employee been trained? -
  Because there are no procedures for processing
  new employees.
• This process can go on if it is determined, via
  logical progression, that additional factors have
  a direct bearing on the outcome.

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Root Cause Analysis 5 Why Example

• As you can see from the preceding example, asking
  why is an extremely simple and effective way to
  determine root cause.

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Root Cause Analysis Fishbone Diagrams
Fishbone diagrams help to identify the 6 Ms
(potential causes) that may have contributedto
the undesirable condition or problem.

• Man(People)
• Machines
• Mother Nature(Environment)
• Methods
• Materials
• Measurements

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Root Cause Analysis Fishbone Method

• Great brainstorming tool!
• Focuses on the cause, not the symptoms.
• Identifies areas that may need further
  investigation.
• Process can be enhanced by adding 5 whys.

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Root Cause Analysis Fishbone Diagram

1. Draw the diagram with the issue to be studied as
   the fish head.

Aircraft is damaged
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Root Cause Analysis Fishbone Diagram

1. Label each bone of the fish.

Man
Machine
Methods
Aircraft is damaged
Mother Nature
Materials
Measures
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Root Cause Analysis Fishbone Diagram

1. Through brainstorming, identify factors in each
   category that could affect the undesirable
   occurrence.

Man
Machine
Methods
Training
Tug
Behavior
Maintenance
Driving
Tow Bar
Aircraft is Damaged
Rain
Manuals
Speed
Tools
Wind
Gauge
Mother Nature
Materials
Measures
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Root Cause Analysis Fishbone Diagram

• Upon completion of the fishbone, analyze the
  results.
• Then, list the items that were identified in
  priority order.
• This brainstorming technique, when properly
  applied, can be helpful in determining a root
  cause to an undesirable condition or problem.

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Root Cause Analysis

• Remember, the objective of root cause analysis is
  to identify the real cause of a problem, not the
  symptoms.
• Hopefully, these simple tools will help you to do
  just that!