February 21, 2011 | Barb Carr

Better Initial Information Collection

Better Initial Information Collection

Submitted by: Bill Missal, Senior Aviation Safety Inspector
Company: FAA, Alaska

Challenge

Field investigators that, unfortunately, may not be trained in the use of TapRooT® collect initial information and then send it to trained investigators to analyze the root causes of aviation accidents using TapRooT®. The untrained field investigators may not collect all the information needed to complete a SnapCharT® or analyze root causes using the Root Cause Tree® (parts of the TapRooT® System). This sometimes caused the trained investigators to have to go back and ask questions at a later date when those being interviewed might forget or confuse facts that might have been remembered immediately after the accident.

Action

Because the FAA in Alaska is a licensed TapRooT® User, we received permission from System Improvements to develop a pre-printed list of questions for these investigators based on the 15 Questions (Human Performance Troubleshooting Guide) of the Root Cause Tree®. these questions were distributed to the field offices and are used by field investigators to help collect better information.

Results
The field investigators use the list in their interviews and collect better information that is included in their files and sent to the staff personnel that perform the root cause analysis. This result better initial information collection is fewer unanswered questions, less lost information, and better root cause analysis by the trained investigators who use the information when performing the root cause analysis using the TapRooT® System.

Categories
Root Cause Analysis
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