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Many Causes, Which is "Root?"


The search for causes of Flight 5191's crash (Letters to the Editor)

Follow up to the Lexington crash and more contributing factors. I think part of the lesson here is 1) lack of proactive problem solving and 2) a combination of MANY factors must go wrong for a plane to crash.

“Was it too expensive to have had a person drive out in a pickup with a large illuminated “X” to mark the runway? They have done so since the crash.

Was it too expensive to have had another air traffic controller in the tower to assist the one who appeared to have had his hands full? The FAA says it's going to add one.

Is it too expensive for Comair to install a device that tells you you're on the wrong runway. It would cost $18,000 per plane. That works out to $367.35 per life that was lost.”

Here is a picture of the “X” that blocked the runway AFTER the crash. That's a fine example of REACTIVE problem solving.

Note how some of the letters to the editor talk about how we need to stop blaming people (the pilot) and stop the witchhunt. I saw on CNN this morning that there was only ONE air traffic controller working at the time, when they should have have TWO. And he was tired after working extra shifts. So many factors contributed here, how do you determine the root cause? Lots of “Why's” to ask for each of these contributing causes.

I'm driving from Kankakee IL to Oxford OH this morning (GO CATS!), which is far less safe than flying, ironically enough. It's a matter of convenience to drive — you can't exactly fly between those cities.

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Mark Graban is an internationally-recognized consultant, author, and speaker who has worked in healthcare, manufacturing, and startups. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent book is the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus. He is currently writing his next book, tentatively titled Measures of Success.

1 Comment
  1. Mike Wroblewski says

    Hi Mark,

    Great post except for your last point. As I have always stated, if your root cause analysis stops at a person (usually after asking why only 1 time), you have not gone far enough. Ask more Why’s and look at the process. As for the point I disagree, Go Redhawks! (Miami University class of 1982!) Have a safe trip and losing final score. Mike

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