1. 1 Kevin O’Connor Airworthiness Surveyor Civil and Military Design, Production & Continuing Airworthiness Root Cause Analysis Project…

2. 2 Root Cause Analysis Project.  To promote and encourage the better use of Root Cause Analysis and to facilitate more effective corrective action to prevent repeat findings, MOR’s, quality issues.  To develop Surveyor root cause continuation training. (An understanding and to give better descriptions of finding raised.)  To develop a surveyor root cause corrective action guide.  To achieve a better response from industry and prevent repeat findings..

3. 3 Root Cause Project Timeline:  Assigned project - Dec 9th Group Meeting to discuss the project framework  Group : Catherine Leach, Matt Lillywhite, Kevin O’Connor, Paul Dyer.  Project start - December 2015  Included internal CAA analysis and input from industry.  Root cause procedures and methods have been gained from Airbus, Rolls Royce, Boeing and BP, AIM, Air Tanker & Marshalls Aerospace.  Presentation by Airbus & Rolls Royce February 2016  Also information received from EASA.

4. 4 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY Root Cause – Corrective Action 4

5. 5 Root Cause Project Questions to address: 5

6. 6 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY Stop! - Put out fire Then continue – Assess impact Contain parts affected Notify customers if needed 6

7. 7 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY Who owns the problem? Who has a stake in the outcome? Owners of problem and solution? Who knows the process? Who will have to implement and live with the corrective action? 7

8. 8 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY Understand the Problem! Is there just one Problem? Was the problem predicted? Why did the event occur & why was it not detected? IT IS NOT: what cause the event What to do next Explanation of event 8

9. 9 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY Data collection is iterative and might not answer all questions Know what to look for Interpretation of data (what it tells you – what it doesn’t) Go to the scene of the event Look for Where Who - to talk to, to understand When Operational/environmental conditions Communications Sequence of events Physical evidence Recent changes Training Any history of event? Go in person But, remember – don’t believe anything anyone ever tells you and only half of what you see. 9

10. 10 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY NOT Root Causes: Operator Error or Honest Mistake; Didn’t include the step in our internal process; Didn’t know we had to. …. These all prompt the question “why?” Direct Cause Contri buting Cause Root Cause Why?Why?Why?Why?Why?Ah! Direct – what led directly to the event Contributing – causes that relied on something to happen to lead to the event Root – the last cause in the chain 10

11. 11 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY If the operator was replaced, could the next person make the same mistake? If so, then this is not root cause. Direct Cause Contri buting Cause Root Cause Why?Why?Why?Why?Why?Ah! Operator error ? Were there: Proper instructions; proper tools; proper training; clear steps? Was the process complex? The operator made a mistake – why did nobody notice? Just keep asking “WHY?” 5 whys is typical in the chain – not always the case Do you have ownership of the chain end – is it in your control? If ownership is elsewhere – they need to be brought into the team Root cause – the fundamental reason for an event, which if corrected would prevent recurrence 11

12. 12 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY Direct Cause Contri buting Cause Root Cause Why?Why?Why?Why?Why?Ah! Contri buting Cause Root Cause There can be more than one root cause! Test the Chain – start at root cause and work back to event. 12

13. 13 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY Corrective Action – A set of planned activities implemented to permanently solve the problem. Specific Actions can change the direct cause Corrective actions can change the direct, contributing and root causes Test the Actions Is the risk of event lowered? Are there adverse effects due to action implemented? Assign actions to those on the team – with an interest! 13

14. 14 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY Design the failure out of the process Make an error impossible to occur or obvious to detect Useful when worker or customer can easily make a mistake When small errors can cause major problems later Examples: Asymmetrical pins on electrical plug ATM machines – card issued before money 14

15. 15 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY Follow up – by a team member to verify corrective action implementation. … and … Assessment – independent review to verify if corrective action has prevented recurrence. 15

16. 16 Event Form Team Containments and Immediate Corrective action Identify Problem Contributing Determine Causes Gather & Verify data RootDirect Determine CA Mistake Proofing Implement Follow-up Accept able? Done Loop back NY Is the Corrective Action acceptable? Determine means to measure effectiveness. Did the CA work? YES??? Document it!!! 16

17. 17 Root Cause project 17 So we are all: Singing from the same hymn sheet Checking apples for apples And that we are all using a common language. To promote and encourage the better use of Root Cause analysis and to facilitate a more effective corrective action to prevent reoccurrence to findings, MOR’s, quality lapses. Surveyor training Root Cause User Guide

18. 18 Questions?