Underlying Benefit of Fishbone Diagram in Aviation SMS

Fishbone diagram libraries provide many opportunities and benefits for aviation service providers who decide to adopt fishbone diagrams as a risk management tool in their aviation safety management systems (SMS).

The primary benefit of fishbone diagrams provide is detail.

Fishbone diagrams:

• Identify major and minor root causes of a risk;
• Categorize causes and events by type, such as human, machine, etc.; and
• Provide a comprehensive picture of all the factors that lead to a risk.

Related Articles on Using Fishbone Diagrams in Aviation SMS

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What Is a Fishbone Diagram Library?

What a fishbone diagram library does is take all of the benefits and provide a detailed picture of an organization’s risk profile as a whole. A fishbone diagram library is a complete portrait of:

• All major and minor root causes in the operational environment; and
• Thematic problems that cause safety concerns in the operational environment.

Here are 5 proven benefits of a fishbone diagram library in aviation SMS implementations.

1. State-of-the-Art Aviation Hazard Risk Register

One of the most obvious benefits of a fishbone diagram library is that you will naturally develop a best-in-class hazard risk register. A hazard risk register is not simply a hazard register. It shows hazards, risks, and the relationship between them:

• Lists all hazards that have been classified with safety issues;
• Tracks the number of times hazards are associated with reported safety issues and audit findings;
• Lists identified hazards associated with each risk; and
• Shows risk controls for each hazard.

Over time, a hazard risk register will become an aviation service provider’s primary tool for quickly evaluating the relationship between hazards and risks, as well as where further risk controls are needed. The hazard register should be consulted and reviewed during routine risk management processes. As safety issues enter the aviation SMS' documented risk management process, a risk analysis is performed. During the risk analysis, related "systems" are reviewed to determine whether the risk is acceptable.

Furthermore, because fishbone diagrams break a risk’s preceding events into categories, a library will provide useful oversight for which elements in their organization are causing the greatest exposure (Human, machine, bureaucracy, etc.).

2. Fishbone Diagrams Are Proactive Risk Management

Fishbone diagrams are only concerned with the events and factors that precede risk, such as:

• Underlying causes – i.e. aviation leading indicators;
• Hazards and threats;
• Categories of risk (Human, machine, etc.); and
• Safety events that lead to the risk.

Performing risk analysis in these areas is a primary proactive risk management activity. Proactive risk management focuses on understanding and acting upon safety information before the risk occurs.

The end goal of having a fishbone diagram library is the ability to be better prepared to:

• Identify dangerous threats;
• Identify underlying causes; and
• Make decisions on threats and causes that avoid risks.

Aviation service providers that create fishbone diagrams libraries are essentially documenting their proactive risk analysis activities. A fishbone diagram library is also a proactive risk analysis library.

Related Proactive Risk Management Articles

• Difference between Reactive, Predictive and Proactive Risk Management in Aviation SMS
• What Is Proactive Hazard Identification and Risk Management in Aviation SMS
• From Reactive to Proactive Risk Management in Aviation SMS

3. Thoroughly Understand Underlying Causes

A fishbone diagram library is a complete picture of an organization’s underlying causes. Other risk management tools will:

• Provide a cursory understanding of underlying causes; or
• Only account for primary underlying causes of a safety event.

Fishbone diagrams on the other hand:

• Account for all major and minor underlying causes of safety events;
• Provide a detailed understanding of all underlying factors involved in safety events; and
• Categorize underlying causes by their type – human, machine, etc.

In short, fishbone diagram libraries provide aviation service providers with the most thorough understanding of the root causes possible.

Related Articles on Root Cause Analysis in Aviation SMS

• How to Conduct Root Cause Analysis in Aviation SMS
• Is Root Cause Analysis Proactive or Reactive?
• Proactive Risk Management: What Root Causes Say about Management

4. Easily Develop List of Aviation Leading Indicators

Aviation leading indicators are used to quantify and monitor the behaviors, attitudes, and functional elements of the aviation SMS that lead directly to risks. Aviation leading indicators essentially monitor underlying causes.

As discussed above, fishbone diagrams provide a complete picture of a safety event’s root causes. What a fishbone diagram library allows a company to do is:

• Identify thematic underlying causes in their organization;
• Evaluate which underlying causes can be quantified into hard data; and
• Crate safety metrics for those underlying causes – i.e. leading indicators.

Having a fishbone diagram library without having a list of leading indicators that are being monitored would be like going ice skating without ice skates. I would even go so far as to say that one of the primary purposes of fishbone diagrams is to gain the ability to quantify relevant root causes.

5. Develop Superior Proactive Risk Controls

In order for risk controls to do their job efficiently, they need to:

• Address a very specific safety need;
• Be relevant to that need; and
• Impose a barrier that avoids or mitigates a threat.

Proactive risk controls are designed to lessen the likelihood of a risk happening. Fishbone diagrams are a fantastic resource for developing superior risk controls because they:

• Provide such a minute level of detail;
• Are all-encompassing of causes and events that lead to the risk; and
• Are broken into categories.

In short, using fishbone diagrams to create proactive risk controls is simply a matter of plugging in risk controls to causes and threats that don’t already have one. Fishbone diagrams contain none of the ambiguity that leads to irrelevant or ineffective risk controls.

Related Aviation SMS Risk Control Articles

• What Is a Risk Control in Aviation SMS: Meaning, Purpose, Application
• How to Implement Effective Control Measures
• How to Monitor the Effectiveness of Control Measures

Final Thoughts on Fishbone Diagram Library in Aviation SMS

An aviation SMS' risk management processes may be either very simple or more complex. The fishbone diagram is only one of many available. Not every organization uses fishbone diagrams in its day-to-day risk management processes. In fact, a fishbone diagram is not necessary for every reported safety issue entering the SMS risk management system.

There are times when more complex safety issues require a visual representation to identify a root cause. Once the fishbone diagram has been completed, the safety team investigates the root cause of the safety issue. Risk mitigation strategies may be implemented to address the root cause.

Again, the fishbone diagram is not a "primary, go-to" risk management tool like the risk matrix, but there can be a time and place to use the fishbone diagram. For safety managers, the biggest hurdle in using a fishbone diagram is to acquire a simple, user-friendly fishbone diagram tool that integrates with their existing SMS database. Luckily, SMS Pro comes with an integrated fishbone diagram tool. Since a particular fishbone diagram may be relevant to multiple safety issues, SMS Pro makes available the fishbone diagram library to manage.

If your SMS risk management processes never need a fishbone diagram, your SMS admin can simply remove the fishbone diagram from your SMS risk management workflow. Again, the fishbone diagram is an SMS Pro option.

For more detailed information on how to monitor safety performance in your aviation SMS implementation, you will find our free guide very helpful:

Last updated November 2023.