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First, we need to disclose that this EXAMPLE RCA is based upon publicly available information from a variety of sources (mostly newspaper articles) and not from any independent investigation conducted by Sologic. Sologic has not investigated this incident in any official capacity, and we do not want to imply that we were in any way associated with this event. The only purpose of this root cause analysis report is for it to be used as an example for our students and other interested parties.
A root cause analysis has two primary goals: 1) Organize a wide array of information from disparate, reliable sources in a way that makes it easier to understand, and 2) Identify a set of evidence-based solutions to present to decision makers.
We were able to create this example from the wide variety of source material avalialbe. But just as we were about to publish it, United themselves released their internal report. In our opinion, this was a very forthright, introspective, candid, and complete assessment. We copied their solutions verbatim and attached them to the appropriate causes on the chart.
A quick note about the financial impact shown in the Problem Statement and the cost of Solutions: No actual financial impacts were disclosed by United, so WE MADE THESE UP with the purpose of showing readers how financial impacts CAN BE disclosed in an RCA report. If United ultimately discloses financial information, we will update this RCA.
Because United's report closely mirrors our own cause and effect chart, we did not write an independent summary statement for this particular example. Instead, we recommend reading the United report in its entirety - it is avaialble here:
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Cause and Effect Summary
Significant Negative Publicity for United Airlines was caused by Passenger injured during forced removal from United flagged flight and General public does not believe forced removal is acceptable and Injured passenger event received significant coverage. Passenger injured during forced removal from United flagged flight was caused by Excessive force used to remove passenger from plane and United needed a passenger to give up their seat. Excessive force used to remove passenger from plane was caused by Law Enforcement team directed called to remove passenger and Law enforcement applied aggressive tactics. Law Enforcement team directed called to remove passenger was caused by Passenger resisted being removed from plane and Once decision is made, there is no mechanism to change and United needed one more seat and United prioritized their employees over customers.
Passenger resisted being removed from plane was caused by United didn't offer enough money to give up seat and/or United didn't provide adequate, acceptable alternate travel options, Needed to be at work the next day. Once decision is made, there is no mechanism to change was caused by Employees are not trained or empowered for this type situation. Law enforcement applied aggressive tactics was caused by Customer would not comply. United needed a passenger to give up their seat was caused by Flight was overbooked and United added 4 employees (traveling as passengers) to the flight at last minute.
Flight was overbooked was caused by Want to assure full planes and Accepted practice by airlines. Want to assure full planes was caused by Goal of maximizing revenue. Accepted practice by airlines was caused by expecting some ticketed passengers to cancel. United added 4 employees (traveling as passengers) to the flight at last minute was caused by United/Republic crew needed to work flight out of Louisville next day and United didn't want Louisville flight (next day) delayed and United did not deploy alternative travel plans for crew. General public does not believe forced removal is acceptable was caused by Passenger had implied contract to remain on flight and Passenger was issued a boarding pass. Injured passenger event received significant coverage was caused by Video footage of injured passenger shared globally and Many people interested in story and General public disagreed with United's initial, public response.
Many people interested in story was caused by Many people could empathize with the injured passenger and Video footage (bloody passenger) was an attention-grabber. Many people could empathize with the injured passenger was caused by Many people have experienced overbooked flights and Airline industry not in great favor with general public. General public disagreed with United's initial, public response was caused by United CEO initially supported the removal of passenger and United didn't take 'ownership' of the problem.
United CEO initially supported the removal of passenger was caused by Internal procedures were followed. United didn't take 'ownership' of the problem was caused by Event occurred on Republic Airlines flight (contractor to United) and United and Republic Airlines are separate companies.