5WH Method of incident or failure investigation

This should be the starting point of any incident or failure investigation. Once you have found answers to all of the questions, carry on with further investigation tools such as the 5 WHYS or any other technique that you are familiar with.

WHAT happened?

 

WHERE did it happen?                             WHY there?

 

WHEN did it happen?                        WHY then?

 

WHO was involved?                          WHY that person or those persons?

 

WHY did it happen?                          At this point use the 5 WHYS tool.

 

HOW did it happen?                         WHY that way?

Frequency histogram and Statistical process control data

Readings Histogram Bins
10

-2

11

-1

9

0

-1

1

7

2

10

3

9

4

11

5

10

6

8

7

5

8

14

9

7

10

10

11

10

12

16

13

14

14

2

15

-2

16

5

17

6

18

8

19

4

20

7
12
6
16
22
7
20
10
21
19
-2
-2
-2
0
4
0
8
8
8
9
9
9
14
9
10
10
9
14
10
12
10
15
17
13
13
13
10
13
13
11
11
11
11
11
11
13
13
13
13
13
13
13
1
3
13
12
12
12
12
12
12
12
12
12
6
15
15
14
14
16
18
18
14
15
16
17
18

How to create a frequency histogram in Excel

A frequency distribution shows how values in a data set are distributed across categories. A histogram shows the same information in a column chart.

To use the Histogram tool, you first need to identify the bins (categories) that you want to use to create a frequency distribution. The histogram plots out how many times your data falls into each of these categories. In this example we are using arrival baggage times. We assume that first class bags have a specification limit of 10 minutes, that is, it should take no longer than 10 minutes after the aircraft arrival to arrive in the baggage centre and placed on the carousel.

Below is a sample of the recorded times:

You can get the complete set of 100 readings in the FREQUENCY DISTRIBUTION DATA worksheet the under CONSULTING, FREE FORMS in the main menu. The histogram uses the 100 items. You can also use the readings for creating a Statistical Process Control chart. See How to create a Statistical Process Control chart.

A        C

10
-2
11
-1
9
0
-1
1
7
2
10
3
9
4
11
5
10
6
8
7
5
8
14
9
18
10
13
11
8
12
6
13
10
14
-2
15
-2

16

4

17

6

18

8

19

4
20
7
12
6
16
Etc

The actual recorded arrival times are shown in Column A. You should have at least 50 readings, otherwise, there is no practical limit.

Below is an example of a frequency histogram showing baggage arrival times at the baggage centre.

This worksheet shows bins information in the worksheet range C2:C24. The bins information shows Excel exactly what bins (categories) you want to use to categorize the baggage arrival data. The bins information shown in the worksheet range C2:C24, presents a range of baggage arrival times from -2 minutes to 20 minutes. The bins don’t have to be in column C, I just put them there to separate the columns for easy reading. Note that the Bins start at -2. This is to account for the times that the bags were put on the carousel belt before the aircraft arrived. Doesn’t happen at your airport? You either have a totally automated system or you have an unusual process. Please share your secret with all the readers of this article.

Creating the histogram in Excel 2016

To create a frequency distribution and a histogram, follow these steps:

Click the Data tab’s Data Analysis command button to tell Excel that you want to create a frequency distribution and a histogram.

When Excel displays the Data Analysis dialog box, select Histogram from the Analysis Tools list and click OK.

When the Histogram dialog box appears, you need to enter the range of the data that you want to analyse.

Use the Input Range text box to identify the data that you want to use to create a frequency distribution and histogram. If you want to create a frequency distribution and histogram of unit sales data, for example, enter the worksheet range $A$2:$A$101 into the Input Range text box. I used 100 as the number of recording that you are analysing. You should use the number of recordings that you are analysing.

To identify the bins that you use for the frequency distribution and histogram, enter the worksheet range that holds the bins into the Bin Range text box. In the case of the example worksheet, the bin range is $C$2:$C$24.

If your data ranges include labels, select the Labels check box.

Tell Excel where to place the frequency distribution and histogram.

Use the Output Options buttons to tell Excel where it should place the frequency distribution and histogram. To place the histogram in the current worksheet, for example, select the Output Range radio button and then enter the range address into its corresponding Output Range text box.

To place the frequency distribution and histogram in a new worksheet, select the New Worksheet Ply radio button. Then, optionally, enter a name for the worksheet into the New Worksheet Ply text box. To place the frequency distribution and histogram information in a new workbook, select the New Workbook radio button.

If you want to enhance the histogram:

Select your choices from the Output Options check boxes to control what sort of histogram Excel creates. For example, if you select the Pareto (Sorted Histogram) check box, and Excel sorts bins in descending order. If you don’t want bins sorted in descending order, don’t tick the Pareto (Sorted Histogram) check box.

Selecting the Cumulative Percentage check box tells Excel to plot a line showing cumulative percentages in your histogram.

In this case, select the Chart Output check box to have Excel include a histogram chart with the frequency distribution. If you don’t select this check box, you won’t get the histogram — only the frequency distribution.

Click OK.

Excel will create the frequency distribution and, if you asked for it, the histogram. See the frequency distribution together with a histogram for the example workbook data in the Quality Data Worksheet under the CONSULTING, FREE FORMS menu.

Using Frequency Histograms in Process Analysis and problem finding

Abstract

Airline passengers do not enjoy waiting for their luggage when they arrive at their destination. Airlines know this so they have agreements with ground handling firms that bags will be delivered to the baggage centre and placed on the carousel within specified times after the aircraft arrival. Ground handling firms monitor the process to fix problems before the airlines find out about them. Baggage centre staff record the times that the bags arrive at the baggage centre. These times are often wrong. This case illustrates the use of frequency histograms to indicate problem areas. The problems found are then analysed using the 5 whys tool to determine the causes/s of the problems. Failure modes and effects analysis is then used to develop corrective action/s. The process is illustrated with photographs. The methodology is not limited to airport work, it may be used in any industry.

Case 640 – Problem solving

Keywords

Quality, problem-solving, frequency histogram, 5 whys, failure modes and effects analysis, process analysis.

INDUSTRY GLOSSARY

Arrival    When an aircraft arrives at an airport. Usually measured as the time that ground staff can begin working. It is not advisable to begin working before the engines are turned off as workers may be sucked into an engine or blown away by the jet blast.

Baggage handling    Transport of passengers’ luggage from the aircraft to the baggage centre where it is sorted and placed on conveyor belts which take the bags to the carousel from which the passengers retrieve them.

Learning objectives

To expose students to actual operational problems in airside operations service delivery and to illustrate both the application and the potential benefits of the scientific analysis of problems to determine the failure modes, their cause/s, possible corrective action to be taken, the selection and evaluation of solutions, and their implementation.

Pedagogical Objectives

The lecturer material is organised around a set of exploratory questions that bring out each of the failures in the case. The questions are posed in stages. After each stage is discussed, the lecturer moves onto the next set of questions.

Target audience    Anyone with an operational or academic interest in problem solving and failure analysis in Air Transport and other processes.

Study time        2 hours

Level    Industry staff or, academically, when quality management and apron operations management appear in the study curriculum

Prior knowledge    Some knowledge of baggage handling – see the resources section.

How to construct a frequency histogram in Excel – There is a post on our site, see the resources section.

Aim    To illustrate the importance of following standard ground handling procedures

Length            14 pages

Published by        Air Transport Research Institute. 4 October 2018

Data source        Experience

Similar cases        10, 230

5 HOWS form and working example

5 HOWS

FAILURE / FMEA #………………..…………….         DATE……………………………………………

PROBLEM………………………………………………………………………………………………………………….

LEADER………………………………………………………………………………………………….

PROPOSED SOLUTION

………………………………………………………………………………………………….……………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

HOW CAN THE PROPOSED SOLUTION BE IMPLEMENTED?

1)………………………………………………………………………………………………….…………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

HOW CAN WE IMPLEMENT THIS?

2)………………………………………………………………………………………………….…………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

HOW CAN WE IMPLEMENT THIS?

3)………………………………………………………………………………………………….…………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

HOW CAN WE IMPLEMENT THIS?

4)………………………………………………………………………………………………….…………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

HOW CAN WE IMPLEMENT THIS?

5)………………………………………………………………………………………………….…………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

………………………………………………………………………………………………….……………………………………………………………………………

HOW TO USE THIS FORM

The analysis is best done by a team of people who are familiar with the process

Failure

Enter the number of the failure either an existing failure or a potential failure you have found using a Failure Modes and Effects Analysis.

Enter the failure description in the space under FAILURE.

Proposed solution

Enter the solution proposed by the team or found in the FMEA process.

How can the proposed solution be implemented?

Enter how the solution can be implemented.

Now you may require resources for the implementation so you need to determine how you can actually achieve the implementation. This may require several steps.

How can we implement this? (2) and so on

Enter how each of the solutions can be implemented until you have exhausted the HOW’s and you have an implementation process. NOTE: you haven’t yet got a plan yet. You still have to allocate resources and set up timetable.

You may have more than 1 implementation solution for a particular HOW. Start another form with the 2nd or 3rd solution. Refer back to the form on which you are working by the failure number from the top of the form and the HOW? Number.

The same applies if 5 HOWs is not enough. For example, in the example below there may be more than one way of checking that the tubes and heads aren’t blocked.

WORKING EXAMPLE

This is based on Case 075; Aero Peru crash caused by tape-blocked pitot heads and static ports.

PROBLEM

Unskilled worker forgot to remove the tape blocking the pitot heads and static ports.

SOLUTION

Supervisor to check that tape is removed which will be hard at night if the tape is the same colour as the fuselage.

HOW CAN THE PROPOSED SOLUTION BE IMPLEMENTED?

Contrasting or luminous tape should be used according the manufacturers specifications.

HOW CAN WE IMPLEMENT THIS?

Draw correct tape from stores if it is available in stock.

HOW CAN WE IMPLEMENT THIS?

Tape is not expensive, carry a large safety stock of the correct tape.

HOW CAN WE IMPLEMENT THIS?

Set a high reorder point in the stock control system.

HOW CAN WE IMPLEMENT THIS?

Signed instruction from management to the Stores manager.

Baggage handling

QUIZ

Explain the following:

Accounting

Apron

Arrival

Baggage

Bay

Cabin

Carousel

Carry-on baggage

Contract

Departure

Flight schedule

GSE

Handling

Mishandled baggage

Operations

Passenger

Pax

Ramp handler

Revenue

Service

Service Level Agreement

Stand

Terminal

Answers at the end of the text.

GROUND HANDLING SERVICES – WHAT YOU WILL LEARN

Ground handlers provide many services to their clients, the airlines. We will list the services relating to baggage and cargo together with how services may be charged for the provision of those services. We will also show where services are sometimes not charged. This means that many Ground Handling companies are NOT getting all the revenue they should mostly because of poor record keeping. All too often services are not recorded or changes to flight schedules are not recorded.

BAGGAGE HANDLING

Baggage is the passenger’s personal belongings like clothes that they take with them when flying.

Baggage may be cabin (carry-on) or hold baggage. Hold baggage is stored in the holds in the belly of the aircraft. It is important that departure baggage be loaded on the correct aircraft and arrival baggage is unloaded speedily and transported to the terminal for the passengers to collect. Baggage which is loaded on the wrong aircraft cause great inconvenience to passengers as they may be without changes of clothing or medication until the they are re-united with their baggage. Arrival baggage which arrives late at the baggage carousels is very upsetting to passengers and hence to the airline.

Service Provision and Pricing methods

Generally, baggage transport is an integral part of arrivals and departures it is included in the arrival or departure cost. However, The Service Level Agreements often list the timing conditions for baggage delivery required by the airline – passengers hate to wait for their bags. Baggage handling staff should record the actual times that the baggage left or arrived at the baggage so that the ground handler can manage the service.

Financial risk

Incorrect baggage departure from and arrival at the baggage centre times in the operations data. In the event of a dispute over late arrival baggage delivery, accurate records are essential to support the handler’s arguments.

Baggage sent to the wrong destination. The airline may impose penalties form mishandled baggage.

Baggage which is delivered late to the carousel. The airline may impose penalties for late baggage.

QUIZ ANSWERS

Accounting    Getting and spending the money you get from providing handling services

Apron        A set of stands or bays, usually, adjacent to a terminal

Arrival        When an aircraft arrives at an airport and is unloaded.

Baggage    Passengers personal belongings

Bay        Part of the apron on which an aircraft is parked. Also known as a Stand

Cabin        The part of the aircraft in which the passengers sit

Carousel    Conveyor belts, one end of which is located in the arrivals terminal on which arrivals bags are placed so that pax can collect their bags

Carry-on baggage    Baggage which passengers take with them into the cabin.

Contract    An agreement between the ground handler and an airline which lists the services to be provided, the charges for the services, and the service levels at which the services will be provided

Departure    When an aircraft leaves an airport

Flight schedule    The planned flights for a period, usually a day

GSE        Ground support equipment; buses, loaders, dollies, etc

Handling    The work done on an aircraft’s arrival and to prepare for its departure

Mishandled baggage    Baggage sent to the wrong destination or left behind at an airport

Operations    The people who do the work around an on an aircraft

Passenger    A person flying on an aircraft other than crew

Pax        A collective noun for passengers.

Ramp handler    Company whose business is to transport people in aircraft

Revenue    Income from services provided

Service        Unloading an aircraft, loading food onto the aircraft, draining the toilets, etc

Service Level Agreement    An agreement, part of the contract in which the ramp handler agrees to provide services within certain time limits set by the airline

Stand        Part of the apron on which an aircraft is parked

Terminal    Building in which passengers prepare to board an aircraft or enter after a flight

WHAT HAVE YOU LEARNT?

The rings of Saturn are composed of lost airline baggage, true or false?

Carry-on baggage is the baggage that pax must put in the hold themselves, true or false?

Business class arrival pax get their bags first, true or false?

Hold baggage is luggage which passengers hold onto, true or false?

Airlines are very strict about baggage arrival on the carousel times, true or false?

ANSWERS

False. This is an urban legend

False, this is baggage taken into the passenger cabin

First, they pay much higher fares for the privilege

The ramp handler’s staff load hold baggage

True, passengers get upset if they have to wait for their baggage

Aeroperú Flight 603 crash

Case 075
Abstract
Shortly after takeoff soon after midnight, an Aero Peru B757
airliner crew discovered that their basic flight instruments were behaving erratically and displaying contradictory emergency messages. The crew declared an emergency and requested an immediate return to the airport. As the flight was at night over water, there were no visual references for the pilots to estimate their true altitude. The altimeter indicated an altitude of approximately 9700 feet, however, the aircraft’s true altitude was much lower. Believing that they were at a safe altitude, the pilots descended cautiously for the approach to the airport. The aircraft crashed into the sea killing all on board. As is often found in practice, there is not one clear root cause that led to the accident, consequently the case explores issues of quality management, information, communication, and decision-making.

Keywords
Ground handling, standard operating procedures, departure, static port, pitot head, exterior cleaning, worker error, quality audit and inspection, training, staff selection, company failure, salaries, safety, situational awareness, air traffic control, procedure manual, problem solving and risk analysis.

Learning objectives
To expose students to actual operational problems in airside operations service delivery and to illustrate both the application and the potential benefits of using risk and failure analysis, in problem-solving and prevention.

Pedagogical Objectives
The instructor material is organised around a set of exploratory questions that bring out each of the potential failures in the case. Reports of the failure (available online) can be used to make the case more interesting. See under the References heading.

Target audience    Anyone with an operational or academic interest in problem solving and failure analysis in Air Transport.

Study time    2 hours

Level    Industry staff or, academically, when quality management and risk appear in the study curriculum

Prior knowledge    Exterior cleaning procedures, see under the References heading

Aim    To illustrate the importance of following standard ground handling procedures

Length    7 pages

Published by    Air Transport Research Institute. 16 February 2018

Data sources    Published sources

Similar cases    83, 93, 165, 259, 287,290, 294, 339, 442.