Root Cause Analysis for Your Problems

There’s something strange happening at 30,000 feet. Last week, two separate American Airlines’ flights were diverted due to a vexing medical mystery.

A week ago, fifteen travelers reported feeling dizzy and lightheaded on Flight 109 from London to LAX.   And late last week, one passenger and three flight attendants on flight 904 from Rio to Miami reported similar symptoms, and pilots turned the plane around . Luckily, upon examination at the returning airport, all passengers were given a clean bill of health.

A variety of possible causes have been suggested, such as scary sounding aerotoxic syndrome from “bleed air” entering the jet cabin from the engine, or a bad chemical reaction between the oven cleaner and the gas used to power the plane’s food ovens. But the root cause has yet to be determined.

Such problems can be devastating to a company. In fact, any of you holding a ticket on an American Airlines’ flight may have a bit more anxiety than usual. And when problems like this occur, there is a tendency to want to act quickly. Author Robert Schaffer refers to this premature tendency to act as an “activity-centered fallacy”. And while quick action might make us feel better, premature solutions like changing the oven cleaner or sealing cracks in the galley without knowing the true root cause can mask deeper problems or miss the true root cause altogether.

If your organization is facing a new problem (or a recurring problem), we recommend the following steps to help rapidly narrow down the root cause so that your solutions are more than temporary fixes.

1. Develop an IS/IS NOT Description of the Problem: Identify key similarities and differences. We know the problem IS occurring on the Boeing 777, but not on other aircraft. The problem IS affecting passengers and crew, but NOT pilots. Were those affected all seated in the same area? By drawing these distinctions, you will more quickly and logically eliminate suspected causes from unnecessary analysis

2. Create a Timeline of Changes: Deviations in performance are caused by changes…always. So, make a timeline of any known changes you have made in people, process, equipment, materials or environment that could be causing the problem. Changes made after the first incident will not be the root cause.

3. Test Possible Causes: Causes that fit your IS/IS NOT description are still just hypotheses and need to be tested as quickly and inexpensively as possible. Before introducing large-scale changes, find ways to test your hypotheses in a controlled environment.

At Action Management Associates, we have over 35 years of experience helping our clients quickly identify the root cause of problems. If you would like to explore strategies to get to the bottom of your own mysteries, give us a call! We’d love to help.


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