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Lessons from a US Navy Pilot: How L&D Can Use a Root Cause Analysis to Eliminate Future Mistakes

Learning and Development (L&D) professionals can sometimes find themselves in situations where their solutions fall short of the desired learner experience due to errors in content or other inconsistencies in the learning solution. Results that are not aligned with intentions quickly erode the value of any strategic initiative and can ultimately result in a significant backlash. We all like to think that perfection is possible to achieve in any important effort that we take on. Unfortunately, perfection can be a desired destination that is extremely difficult, and arguably impossible, to reach. When inevitable imperfections find their way into our prized solutions, conducting a thorough Root Cause Analysis (RCA) can enable L&D organizations to take a proactive position towards continuous improvement, phase out errors, and bolster the prestige of solutions.

L&D can have a direct impact on minimizing the implication of the error through an in-depth analysis and successfully implementing the necessary corrective actions identified in a well-conducted RCA.

Example of an RCA in Action

Routine Recovery to the Aircraft Carrier

Everything was routine during our flight. The skies were clear. The seas were calm. Our assigned mission was a success. Our only remaining task was to land our A-6 Intruder on the deck of the USS Enterprise safely. Steve, my Bombardier/Navigator (B/N), and I enjoyed subtle change of colors from the late afternoon sky as we orbited overhead the ship. Since we still had an hour left of daylight, we anticipated that our recovery to the ship would also be routine.

We then received a curious call on the radio from the ship’s tower, “Lizard 506, switch to your Squadron’s maintenance frequency.”

As Steve made the switch on the radios, we looked at each other wondering what this was all about. Steve checked in to Maintenance, “Lizard Maintenance, this is 506. What’s up?”

The Maintenance Officer then gave us the news, “Hey 506, we are going to ask that you do a straight-in approach to the ship. We suspect that a large flashlight may have been left in your aft compartment bay. We recommend that you minimize your maneuvering to prevent any possible damage to your flight control cables.”

As we each did a double-take, Steve acknowledged the instructions, “506, roger. We’ll switch to approach for the straight-in.”

With this, I gingerly set up for a smooth, straight-in approach to the aircraft carrier. As I carefully worked my way into position, I noticed the clock on the instrument panel showed that it was 7:20 p.m.

I then commented to Steve, “I bet they noticed the issue during the shift change tool inventory.” Steve agreed, “Yeah, that makes sense.”

Thankfully, Steve and I successfully recovered to the ship without any incident. After we landed, a maintenance crew discovered the missing large flashlight in the aft compartment bay of our aircraft. A potential aircraft accident was avoided.

As L&D practitioners, we don’t always learn about the impact training interventions have, but they can have significant implications. It’s critical to design learning to improve the organization’s metrics, and it starts with fully understanding and analyzing the root causes and behavior changes.

Analyzing Failure

It’s human to make mistakes, and we live in a complex world where mistakes are a natural product of our behavior. So, what can we do? The L&D community does not have the same level of consequence as carrier aviation necessarily; however, for both large- and small-scale L&D operations the results can still be significant. When these issues arise, conducting an in-depth analysis can be instrumental in helping minimize the chance that the error will happen again.

In his book, Black Box Thinking, Matthew Syed provides his perspective on learning from failure:

“Failure is thus a signpost. It reveals a feature of our world we hadn’t grasped fully and offers vital clues about how to update our models, strategies, and behaviors. From this perspective, the question often asked in the aftermath of an adverse event, namely ‘can we afford the time to investigate failure?’, seems the wrong way around. The real question is ‘can we afford not to?’

What Is an RCA?

RCA is an in-depth analysis of why an unexpected error occurred. The types of root causes to these errors often fall into several categories that include flawed processes, flawed systems, improper deviations from processes, or flawed tools.

The goal is to leverage the RCA process to minimize the likelihood of making the same mistakes over and over. Effective RCAs look at the incident from a holistic perspective and, in many cases, the mistake is merely a symptom of a broader issue.

Why Should We Conduct RCAs?

Learning professionals oversee the creation and delivery of content that ultimately is consumed and applied by learners, business partners, and other colleagues. When something is wrong, it is our nature to fix the most immediate issue of concern. Once the emergency is properly addressed, it is easy to shift seamlessly back to normal. To truly establish a system of continuous improvement, we must look beyond the tactical aspects of the issue and address it from a strategic perspective.

Here are three reasons why L&D organizations should conduct RCAs.

Errors Impede the Ability to Provide Valuable Experiences that Help Learners Improve and Grow

As L&D professionals, we constantly strive for a valued experience that enables learners to overcome impending hurdles successfully, allowing them to improve and grow in their role. Inadvertent flaws in our carefully designed solutions erode the learner experience, increasing the challenge of realizing this growth. RCAs allow you to fully explore the nature of these errors and establish processes to prevent repeating them in the future.

The Complexity of Learning Tools Makes It a Challenge to Prevent Errors

The learning landscape is constantly changing. Software solutions that include learning management, content authoring, social learning, mobile learning, and virtual classrooms all have their own individual quirks that can lead to errors. Rather than allow the many challenging subtleties of these solutions to manifest themselves into unwanted errors, RCAs provide a proactive means to highlight these subtleties to ensure their proper use going forward.

Learners Are Turned Off by Flawed Content

In many business environments, the number of consumers for content can quickly reach into the tens of thousands and beyond. As a result, the consequence of a content failure can be significant. Smaller organizations that do not operate on this larger scale still have stakeholders that can become frustrated with flaws—especially ones that are repeated. Successive problems can have a significant effect on the level of confidence of stakeholders. Over time, data collected from RCAs can point to trends and gaps in process. Over time, learners’ confidence increases as these gaps are subsequently corrected.

How to Conduct an RCA

A well-conducted RCA requires the right mindset that strives to look beyond the immediate issue and allows the crucial details to bubble up. A solid approach leverages the following key steps:

Gather All Relevant Details

Comprehensive data can make the difference in accurately determining the true root cause. During the early analysis, it is important to understand the true scope of the issue:

  • How was the error discovered?
  • How many learners were affected?
  • How was technology involved?
  • Did any existing processes/procedures come into play? How were they followed? Who are the owners?
  • What are the actions that occurred after the error was made?
  • Did any unusual pressures (time constraints, staffing challenges, etc.) play a role?
  • Has this issue ever happened before?
  • What was the level of experience of the people involved?
  • Were multiple organizations involved? How do they coordinate the work?

When interviewing the people involved, it is important to establish an open atmosphere. The goal of the RCA is not to place blame. Instead, the goal is to see what truly caused the issue and what can be done to prevent it from happening again.

Analyze the Root Cause and Corrective Action(s)

Once all the details are collected, time should be set aside to analyze the data. What are the contributing factors that led to the incident? Did the actions before, during, and after the incident help mitigate the error, or did they make things worse. How robust are the processes? Were there any challenges to properly leveraging the processes or procedures?

Taking a holistic view of the circumstances enables a more accurate determination of the root cause and any necessary corrective actions.

Review and Communicate the Results of the RCA

Once completed, the draft results should be reviewed with the key stakeholders and relevant individuals involved. This review is crucial to ensure that the data was accurately interpreted and that no other uncovered details exist. Revisions are common at this stage. Once the final report is complete, a broad communication should be provided to the affected areas of the organization(s) to ensure sufficient awareness. A record of the final report should also be filed and made available that allows people to call it up in the future.

Enabling Excellence Over Time

As L&D professionals, we strive to enable performance excellence within the organizations we support. We celebrate when our solutions deliver measurable results to the business. Likewise, we are disappointed when the high standards are missed due to circumstances that are ultimately within our control. Despite our best intensions, we are susceptible to errors. If we do not proactively go after the mistakes that stand in the way, our solutions suffer. As I have learned from the aviation community, a proactive mindset regarding errors can enable excellence over an extended time.

Reflection on Our Routine Aircraft Carrier Recovery

The next day after our “routine” carrier landing, I met up with Mike, the First-Class Petty Officer who had been working on our jet prior to the flight. Mike let me know that he had been the one that left the flashlight in our jet. He had no explanation to the error, other than he just screwed up. The look on Mike’s face showed me that this was a painful conversation. I asked Mike, “Did you catch the issue during the shift change tool inventory?” He said, “Yes, it was then I recognized that I left the flashlight in the jet.” Had it not been for the tool control procedures that were designed from the result of the US Navy’s commitment to RCAs, our “routine” flight might have had a significantly different ending.

Although the level of consequence between carrier flight operations and strategic L&D initiatives are significantly different, the approach to minimizing future errors is valid for both environments. Rather than glossing over missteps, L&D organizations can realize long-term, exceptional performance by applying RCAs to them. Eliminating future mistakes may be impossible; however, we can have a direct impact on minimizing the implication of the error through an in-depth analysis and successfully implementing the necessary corrective actions identified in a well conducted RCA.

About the Authors

Greg Renner

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