• No caller had a topic to start with so the first topic brought up by Walter for discussion was the lack of root cause analysis (“RCA”) that he is seeing in some of his audits. It is common to just treat the “effect” or “symptom” of a reported problem and not dig down into what the possible underlying hazard that is the “cause” that ultimately made the problem happen.
• There are several techniques published that offer a way to do a RCA. Some techniques are proprietary to a particular vendor that sells it as a class or service.
o In the IS-BAO SMS Tool Kit there is the SMS Guidance Manual that discusses RCA briefly.
o The FAA has a Quick Reference Guide at http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/afs/afs900/sms/ media/newsletter/sms_qr_guide.pdf.
o Another great publication is the ICAO Safety Management Manual at http://www.skybrary.aero/bookshelf/books/644.pdf.
• One of the simplest methods is called the “Five Whys” in which the analyzer keeps asking the question “Why did that happen?” going down to five levels of possibilities. More about this can be read at http://en.wikipedia.org/wiki/5_Whys.
o Walter used the example of one operator that upon preflight, they found the aircraft battery dead. They were able to fix the situation before departure, but a hazard report was written. Using the five whys:
§ Why was the battery dead? Because the aft equipment bay utility light was left on.
§ Why was the light left on? Because an AMT was back there working and forgot to turn the switch off.
§ Why did the AMT forget to turn the light switch off? Because he was interrupted from what he was doing and left in a hurry.
§ Why was he interrupted? Because he was needed to work on another aircraft that had a problem right then.
§ So just after 4 whys, it is found that one of the possible underlying issues was a work interruption situation. It is better to deal with that problem, which could have manifested itself in many other ways than just the battery being dead.
• One caller said that with RCA analysis could be relatively easy when there is an easy way to fix the problem, to assess the blame. But if one keeps drilling down into the RCA, it can reveal an organizational issue, such as lack of staffing, that is difficult to bring up to management.
• Another caller mentioned the RCA technique called HFACS. He provided the following additional information following the call:
o Dr. Wiegmann and Dr. Shappell developed the program for the Navy and Marine Corps - it is now adopted DoD-wide: https://www.nifc.gov/fireInfo/fireInfo_documents/humanfactors_classAnly.pdf
o Dan McCune - Safety Chief at ERAU does a good job with a 2-day course. Here is the link to the workshops: http://hfacs.com/
• Another called brought up the topic of safety communication, and asked the other callers what some of the ways they use to get safety messages out to the employees. He said they use a computer drive that has a “read and initial” process whereby the reader has to acknowledge that they have read the message.
o Several callers expressed that they either use an online process similar to what was just described, or use email with a read receipt sent back to the sender.
o One caller mentioned that an email read receipt return is not necessarily proof that the receiver actually read the message.
o Another caller mentioned that it is probably best to follow up at the next department meeting to reemphasize the safety messages that have been emailed since the last meeting. It is also good to be sensitive to the importance of the information that is going out. If it is very important, it is probably best to not just trust emailing it out, but rather to call or meet with each member of the flight department to make sure they have received and understood the message.
• Another caller brought up the issue related to interruption to routine. He said that when someone is made to change from their routine due to circumstances, like the hurry associated with a pop-up trip. They had an experience that due to a hurry-up situation, the FMS was not programed properly and it wasn’t caught until a normal routine check to see that the programed Vspeeds on each side did not match. Not only was this not good, it could have been worse with the fuel programming.
o Another comment was shared that that is the reason to have checklists. Need to make sure one is not so complacent with checklists.
o There was another comment about complacency. It is an issue of culture and the work environment.
• That concluded the call. It was 30 minutes in length. Next call is Tuesday, March 25th, at 11:30am Eastern time. Thank you for your participation. Please let other Safety Officers know of the opportunity to join the call or to access these meeting notes.
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