Root Cause Analysis Workshop

 Self Introduction  Definition WORKshop  Structure of the workshop  Duration workshop Root Cause Analysis Workshop

Air Asia 8501

 Crew reset flight augmentation CBs for rudder travel limiter system  Auto pilot and auto throttle disengage  Loss of control of aircraft  Rudder Limiter System Failure-electronic card solder joint crack  23 rudder system write up’s in 12months Air Asia 8501

a causal factor is a contributing factor but not originating nature What is a Causal Factor?

a common consensus can probably be found in determining a root cause as “a cause, if altered or removed, would have either have eliminated or substantial altered the outcome.” What is Root Cause?

 Upgraded training  Enhanced safety standards Air Asia 8501-Company Mitigation

 Was the lack of training the root cause?  Is the absence of enhanced safety standards the root cause? Air Asia 8501-Root Cause

Root Cause Analysis

5-Why’s-The Reason for Using it

A concept of accident causation Activities over which any organization has a reasonable degree of direct control Factors that directly influence the efficiency of people in aviation workplaces. Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect. Resources to protect against the risks that organizations involved in production activities generate and must control. Conditions present in the system before the accident, made evident by triggering factors. Latent conditions trajectory

Fishbone or Ishikawa Diagram

Challenges with Solving a Problem

Challenges with Solving a Problem— Quick Solutions

Challenges with Solving a Problem- Accepting the Current Situation

Summary (Coming today to this forum is the start to the process ( This step is the hardest as it over comes the inertia within

Thank You