Investigation and Root Cause Analysis Guideline

摘要

This document provides guidance for investigating and conducting root cause analyses of safety-related incidents associated with Air Force maintenance actions. The impetus for and sole focus of this document are incidents in which detectable cracks in safety-of-flight aircraft structure have been missed by approved nondestructive inspection (NDI) techniques. The tools defined herein, however, can be adapted and utilized for the investigation of any maintenance-related incident. The role of root cause analysis in incident investigation is emphasized in this document. Root cause analysis is intended to answer the questions 'What,' 'How,' and, most importantly, 'Why' regarding an incident. A successful root cause analysis will identify the, controllable, causal factors that can be corrected to eliminate the recurrence of similar incidents in the future.