By directing corrective measures at root causes, it is hoped that the likelihood of problem recurrence will be minimized. However, it is recognized that complete prevention of recurrence by a single intervention is not always possible. Thus RCA is often considered to be an iterative process, and is frequently viewed as a tool of continuous improvement.
Root cause analysis forms the most critical part of successful corrective action, because it directs the corrective action at the root of the problem.
1. Define the problem.
2. Gather data/evidence.
3. Ask why and identify the causal relationships associated with the defined problem.
4. Identify which causes if removed or changed will prevent recurrence.
5. Identify effective solutions that prevent recurrence, are within your control, meet your goals and objectives and do not cause other problems.
6. Implement the recommendations.
7. Observe the recommended solutions to ensure effectiveness. Variability Reduction methodology for problem solving and problem avoidance.
Ishikawa Diagram/FishBone Diagram
Kaoru Ishikawa (1915-1989) was an influential quality management innovator best known in North America for the Ishikawa or cause and effect diagram that is used in the analysis of industrial process. Ishikawa diagrams were proposed in the 1960s, by Kaoru Ishikawa who pioneered quality management processes in the Kawasaki shipyards, and in the process became one of the founding fathers of modern management.
It was first used in the 1960s, and is considered one of the seven basic tools of quality management. It is known as a fishbone diagram because of its shape, similar to the side view of a fish skeleton.
Elements and Causes
Causes in the diagram are often based on a certain set elements as described below. Cause-and-effect diagrams can reveal key relationships among variables, and the possible causes provide additional insight into process behavior. Elements and Causes should be derived from brainstorming sessions. Then causes should be sorted to gather similar ideas together. These groups should then be labeled as categories of the fishbone. Elements should be specific, measurable, and controllable.
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Basic elements of root cause
-Defective fuel or oils (contamination)
-Wrong fuel or oils
-Lack of other resources (parts, cleaning supplies, other)
2.Machine / Equipment
-Incorrect aircraft selection
-Poor maintenance of aircraft or design - Poor aircraft or equipment placement
-Defective aircraft or equipment
-Orderly cockpit, workplace, landing area clear of debris
-Landing areas and staging areas suitable for pilot (size and approach)
-Work area difficult conditions to work in. (Outdoors, extreme temperature, mosquitoes, heat, mud)
-Physical demands of the task (Fatigue, quality of sleeping quarters and food)
-Forces of nature icing, snow, hail, high winds.
-No or poor management involvement
-Inattention to task - Procedures not followed
-Other (aerobatics, inattention, horseplay....)
-No or poor procedures
-Practices are not the same as written procedures
-Training, experience or education lacking
-Poor employee involvement
-Poor recognition of hazard
-Previously identified hazards were not eliminated