aviation assignment for MGMT

Root Cause "Success" Analysis Root cause analysis is an approach for identifying the underlying causes of why an incident occurred. It's typically used when something goes badly, but can also be used when something goes well. The investigation of US Airways Flight 1549 will include both why the aircraft ditched in the river and why all onboard survived.

DefineStep 1.

AnalyzeStep 2.

PreventStep 3.

Cause Mapping

What's the Problem?

Why did it happen?

What will be done?

1

2

3

Problem Solving • Incident Investigation • Root Cause Analysis

Goals

Causes

Solutions

Goal Impacted because... because... because...Why? Why? Why?

"Miracle on the Hudson" Flight 1549

In the Cause Mapping method, the word "root," refers to the causes that are beneath the surface. Most organizations mistakenly use the term "root cause" to identify the one, main cause. A Cause Map visually explains that all of the causes of an incident are required for the incident to occur. The "root" should be thought of as a system of causes to reveal the different options for solutions.

There are three basic steps to the Cause Mapping method: 1) define the issue by its impact to overall goals, 2) analyze the causes in a visual map, and 3) prevent or mitigate any negative impact to the goals by selecting the most effective solutions. For information about investigating and preventing a problem or attending a workshop visit our web site at www.thinkreliability.com or call 281-412-7766.

Cause Mapping Root Cause Analysis

A Cause Map begins on the left with the impact to the overall goals. The questions begin, "Why did this effect happen?" The response to this question provides a cause (or causes), which is written down to the right. The next question is again, "Why did this effect happen?" The cause that was written down last becomes the effect for the next Why question. Anyone who's ever had a three-year-old in their life will immediately recognize how Why questions change a cause into an effect. This is fundamentally how causes and effects link together to create a chain of events. Writing down 5-Whys as a Cause Map, shown below, is a great way to start an investigation because it's so simple. In addition to the standard Why questions, which tend to create linear cause-and-effect relationships, the Cause Mapping method also asks "What was required to produce this effect?" Anything that is required to produce an effect is a cause of that effect. This question, "What was required?," builds a detailed Cause Map that provides a more complete representation of the actual issue.

How to read a Cause Map

Copyright 2009 ThinkReliability

Start on the left. Read to the right saying "was caused by" in place of the arrows.

When an effect has more than one cause, both causes are placed on the Cause Map. Each cause is connected to the effect with an AND placed in between. These causes are independent of each other, but they are both required to produce that effect. An AND is needed when people provide different, yet valid, explanations of a cause. People think of cause- and-effect as a simple one-to-one relationship; an effect has a cause. In reality, every effect has causes.

Captain decided to ditch in

Hudson River

Question: Why did the captain decide to ditch in the Hudson River? - because the aircraft was unable to maintain altitude. - because the plane was already aligned with the river. - because the pilot avoided a landing attempt at an airport.

By asking the captain, he can explain the causes of why he decided to ditch in the Hudson. The causes are linked with an AND because they were all required to produce the captain's decision.

ANDs show where more than one cause is required.

because...

Why?

5-Whys on a Cause Map The 5-Why approach is an excellent example of basic cause-and-effect analysis. Just as a journey of a thousand miles begins with the first step; every investigation, regardless of size, begins with one Why question. The Why questions then continue, passing through five, until enough Why questions have been asked (and answered) to sufficiently explain the incident. The 5-Why approach, created by Sakichi Toyoda (1867 - 1930), the founder of Toyota, is a simple way to begin any investigation. A Cause Map can start with just 1-Why and then expand to accommodate as many Why questions as necessary. Some refer to the Cause Mapping method as "5- Whys on Steroids."

It should be noted that the popular fishbone cause-and-effect diagram starts with the problem on the right and builds the causes to the left. It was created by Kaoru Ishikawa (1915-1989) in Japan. The fishbone diagram builds from right to left because the Japanese language reads from right to left. The Cause Mapping method actually uses Ishikawa's convention by asking Why questions in the direction we read.

C C C C

C

C C C C

C C C C

C CI

CI C

Read the Cause Map Left to Right

Cause Map

Fishbone

because... because... Why?

AND

Aircraft ditched in water

Some causes are linked with AND inbetween Aircraft unable to maintain altitude

Pilot avoided landing attempt

at an airport

Plane was aligned with

Hudson River

AND

AND

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Step 2 is the Analysis of the incident. The cause-and-effect relationships are identified by asking "Why?" questions starting with the Goals that were impacted. While the Cause Map may start linearly, it will expand to provide a detailed view of the entire incident as more information is collected.

Zero Fatalities on the Ground

1

2 Analyze

Define

Safety Goal Impacted

No deaths from impact with

water

Zero aircraft passenger fatalities

Aircraft landed smoothly in

water

Aircraft lost both engines Bird strike

Aircraft unable to maintain

altitude

Safety Goal Impacted

Zero fatalities on the ground

Captain decided to ditch in

Hudson River

Pilot guided aircraft clear of populated areas

Aircraft at sufficient altitude

(3200 feet)

AND

Safety Goal Impacted

No deaths from impact with

water

Zero aircraft passenger fatalities

Aircraft landed smoothly in

water

River was calm

Nose of aircraft kept up

AND

Wings kept level

AND

Aircraft was flown smoothly

Skills of captain (experience)

"Responsive" controls

(with no power)

Boats arrived on scene quickly

No deaths from hypothermia

Passenger exposure to cold temps. minimized

No deaths from drowning

Aircraft floated partially above

the water

Passengers loaded onto

boats quickly

Ferry crews saw plane ditch

Safety Goal Impacted

Zero aircraft passenger fatalities

Safety Goal Impacted

Zero aircraft passenger fatalities

Step 1 is the Definition of the Problem. It's written in an outline format so that it's easy to capture and easy to read. The problem is always defined by the specific impact to the organization's overall goals (the deviation from the ideal state). In the case of Flight 1549 the impact to safety was a positive. All 155 people onboard survived, but it could have been catastrophic. There was also the loss of a $70M aircraft.

Start with simple Why questions.

Zero Passenger Fatalities...from Impact with Water

Add detail as information is collected.

Question: Why were there no passenger fatalities on the aircraft? - because of how smoothly the aircraft impacted the water. - because no one died of hypothermia or drowning. - because no one died from fire. These causes (and more) can be combined onto a Cause Map to accommodate as much detail as needed. See the Cause Map on the next page.

Question: Why were there no fatalities in the city? - because the pilot guided the aircraft clear of populated areas. - because the Captain decided to ditch in the Hudson River. - because the aircraft was at sufficient altitude (3200 feet). It's not a matter of which one is "right." All of the responses above are accurate cause-and-effect relationships which fit on the Cause Map.

Start with simple Why questions.

AND

Question: Why was the plane able to land so smoothly in the water? - because of the skills of the captain and first officer. - because the nose of the aircraft was kept up. - because the wings were kept level. - because the Hudson River was relatively calm.

These specific details are important if other pilots are going to learn from the incident. Another cause is "the aircraft designers accounted for a scenario where the controls would need to partially function with both engines out."

Skills of captain (experience)

Zero Passenger Fatalities...from Hypothermia or Drowning

3 Prevent Step 3 is the selection of specific action items to prevent the issue from occurring.

The recommendations and action items from the actual Flight 1549 incident will be included once they are made available.

What Problem(s), Issue(s) Aircraft ditched in Hudson River, Bird strike, Lost both engines When Date, Time January 15, 2009, ~3:31 PM est Where Geographic location Hudson River, west of Manhattan, near 48th street

Company identification US Airways, Flight 1549 Process (task being done) Passenger flight - New York City (LaGuardia) to Charlotte, NC

Impact to the Goals Safety No fatalities, 150 passengers, 5 crew members survived

Potential was for major loss of life on aircraft and ground Property Loss of aircraft, write-off (estimated aircraft value) 70,000,000$

Loss of passenger belongings ? This incident

Frequency 1x ditching for US Airways

"Miracle on the Hudson" Flight 1549

Copyright 2009 ThinkReliability Page 2 of 3

Captain

Aircraft ditched i t

Wings kept level

Aircraft slowed

Aircraft landed smoothly in

water

AND

River was calm

Nose of aircraft kept up

AND

AND

Pilot is licensed glider pilot

AND

Many flight hours

Specific, recurring training

AND

Safety Goal Impacted

Zero fatalities on the ground

Pilot guided aircraft clear of populated areas

Aircraft at sufficient altitude

(3200 feet)

AND

No fire after aircraft ditched

No ignition sources after

ditching Both engines

scooped full of water

No deaths from fire

Flames from damaged

engine extinguished

Aircraft ditched in waterNo deaths from

smoke inhalation

Safety Goal Impacted

No deaths from impact with

water

Zero fatalities on aircraft

Aircraft was flown smoothly

Skills of captain, first

officer

"Responsive" controls

(with no power)

AND

AND

AND

AND

Boats arrived on scene quickly

Rescue boats were available

quickly

No deaths from hypothermia

Passenger exposure to

cold water/air minimized

No deaths from drowning

Aircraft floated partially above

the water

Passengers loaded onto

boats quickly

Ferry crews saw plane ditch

AND

AND

Passengers waited on

forward floating slides

AND

Ports on bottom of aircraft closed ?

"Ditch switch" used ?

AND

Winds calm

AND

Floating slides deployed

Girt bar installed properly

Flight attendants

completed task

Slide functioned properly

Passengers waited on wing (stood in water)

Main cabin passengers

quickly exited window exits

Passengers in aft section

moved to wing exits

Window exits opened quickly

Exit-row passengers

studied instructions

No aft exit available

Aft doors were bent, damaged

Tail of aircraft impacted water

AND

Water level was rising in aft

cabin

Water leaked through partially

open aft exit

AND

Aircraft lost both engines

Bird strike

Aircraft unable to maintain

altitude

Captain decided to ditch in Hudson River

Pilot believed ferrys, boats

could respond quickly

Pilot avoided a landing attempt

at Teterboro

Plane was aligned with

Hudson River

Pilot avoided a landing attempt at LaGuardia

AND

AND

AND

AND

Fuel on water

AND

Cause Map Start with any one of the goals that have been impacted. Read the Cause Map from left to right using the phrase "was caused by" in place of the arrows.

version Int-1 Jan-09 Copyright 2009 ThinkReliability

Aircraft ditched in water

Loss of aircraftProperty Goal Impacted

Passengers braced for

impact

AND

No fire in cabin

AND

Aircraft floated partially above

the water

AND

No fire after aircraft ditched

"Miracle on the Hudson" Flight 1549

Engine, instrument

malfunction ?

Computer, software issue

?

AND/OR

AND/OR

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