How do you conduct a root cause analysis for aerospace safety and reliability incidents?

1 Data collection

The first step of RCA is to gather as much relevant data as possible about the incident, such as the location, time, weather, personnel, equipment, procedures, and outcomes. Data can be obtained from various sources, such as reports, logs, records, interviews, observations, photos, videos, and simulations. The data should be verified for accuracy, completeness, and consistency, and organized in a logical and chronological manner. Data collection helps to establish the facts and context of the incident, and to identify any gaps or anomalies that need further investigation.

2 Causal factor identification

The second step of RCA is to analyze the data and identify the causal factors that contributed to the incident. Causal factors are the events, conditions, actions, or omissions that directly or indirectly caused or influenced the incident. They can be classified into different categories, such as human, technical, organizational, environmental, or external. Causal factor identification helps to trace the sequence and interaction of events that led to the incident, and to determine the scope and level of impact of each factor.

3 Root cause identification

The third step of RCA is to identify the root causes that underlie the causal factors. Root causes are the fundamental reasons or explanations that answer the question "why" the causal factors occurred. They can be related to issues such as design, maintenance, training, communication, culture, policy, or regulation. Root cause identification helps to reveal the systemic and latent problems that need to be addressed to prevent similar incidents from happening again. To identify root causes, various tools and techniques can be used, such as the 5 Whys, fishbone diagrams, fault tree analysis, or barrier analysis.

4 Corrective action implementation

The fourth and final step of RCA is to implement corrective actions that address the root causes and prevent recurrence of the incident. Corrective actions are the specific measures or changes that are designed to eliminate or reduce the root causes, or to mitigate their effects. They can be short-term or long-term, preventive or reactive, technical or organizational. Corrective action implementation helps to improve the safety and reliability of aerospace systems and operations. To implement corrective actions, various steps can be taken, such as setting goals and priorities, assigning responsibilities and resources, monitoring progress and performance, and evaluating outcomes and feedback.

5 Here’s what else to consider

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