Safety, Root Cause Analysis and Human Factors

Safety should be on minds each day as aircraft maintenance professionals. We can’t afford to follow unsafe practices in our workplaces. There are many factors that affect safety, and we are honored to have some great contributing writers who discuss safety in the pages of D.O.M. magazine each month.

One of our long-time contributors, Patrick Kinane, often discusses different aspects of safety in his articles. This month is no exception with his article on Complacency (see page 28). In part of his article, Kinane discusses root cause analysis. He is critical of those who use human factors (aka “The Dirty Dozen”) as part of root cause analysis. He says that those who use the Dirty Dozen to find the root causes of problems aren’t addressing the root cause, but rather a symptom. He says, “Unfortunately the “Dirty Dozen” is seen as the great list of causal human factors and we place too much emphasis on its usage. It has become a crutch to lean on to identify causes but often problems persist.” Kinane uses an analogy later in his article to explain this mentality. “While employed at a major airline I went through a root cause training session. It was a very robust training course in sound root cause analysis, but the odd thing was that the root cause analysis was done after employee discipline has been administered. Yes, you heard that correct, ready-shoot-aim.”

Some might read Kinane’s article and think that we should not focus on human factors, and instead focus on root cause analysis. Those who think this would be wrong. Kinane is not arguing against the importance of understanding human factors and how they affect us in the workplace. Rather, he is making the case for implementing effective root cause analysis processes in our workplaces.

Kinane’s story of his root cause training session reminds me of an experience I had with a previous employer. I was working in the QA department at a repair station, and we were transitioning from a “blame game” mentality to a culture of root cause analysis. It was easire for some to accept than others. In our previous blame game culture, if an incident or accident happened, the typical response by management was: “Bob, you dropped a tool on the wing and damaged it. We are going to give you three days off without pay.”

But the new processes we were trying to implement required the supervising manager to write a report including what the root cause of the incident or accident was, and what he or she did as corrective action. Follow-up audits were supposed to ensure the corrective action was appropriate in solving the root cause of the problem.

Apparently, either the training the employees received on root cause analysis was not adequate or some refused to buy in to the new culture. I still remember the first root cause analysis report that came across my desk for review. It read: “Problem: Wing was damaged. Root Cause: Bob dropped a tool on the wing. Corrective Action: Gave Bob three days off without pay.” As you can see, it took a while for us to truly embrace root cause analysis and properly use it in the workplace. The change in our culture didn’t happen overnight.

While understanding root cause analysis is critical, we can’t dismiss the importance of understanding human factors and how they affect us in the workplace. If you want to learn more about human factors, stay tuned. Our new contributing writer, Gordon Dupont, will be discussing human factors in some of his articles in 2015. Dupont is widely recognized as the “father of the Dirty Dozen,” the main human factors that lead to maintenance errors. For those who don’t know about the Dirty Dozen, they are:

• Fatigue
• Stress
• Complacency
• Communication
• Awareness
• Distraction
• Lack of knowledge
• Teamwork
• Lack of resources
• Pressure
• Lack of assertiveness
• Norms

Although The Dirty Dozen can affect each of us, all is not lost. By understanding each of the human factors in the Dirty Dozen, and knowing what safety nets we can put in place as employees and managers, we can help reduce the chances of errors in the workplace. We welcome Dupont’s efforts to better educate us on human factors and safety management systems.

This is our last issue of 2014. We are already working on editorial topics for 2015. We look forward to continuing to provide the aircraft management articles you have come to rely on in your jobs.

Thanks for reading!  – Joe Escobar