RCA

 

The DIA case was, for the Foundation, just that: a case.  If you look at our mission and vision statements (which are based on our values system), we exist because avenues of recourse within our government, especially the military’s office of the Inspector General, simply don’t work.  Let us digress to another fighter pilot story (we love talking about ourselves (and shooting our watches) after all!)…

 

In tactical aviation, we spend far more time planning, briefing and debriefing than we do flying an actual mission.  If I were flying a local tactical sortie, I’d typically spend about two to three hours planning, an hour briefing, about an hour and a half airborne, and then anywhere from thirty minutes to four or five hours debriefing, depending on the complexity of the mission (and how poorly the upgradee performed ;-).  During the debrief, the technique was to first identify some big-picture takeaways, like “Why did #2 die on the initial ingress?” (#2 was typically the youngest and seemed to oftentimes be the one to eat it.)  These questions were termed “Debrief Focus Points”, or “DFPs.”  The flight lead would begin the debrief by jotting a few of them down – they were major events in the mission that the formation needed to focus on during the debrief with the intent to learn and improve.  The aim of the DFP was to identify the string of events, or factors, that were causal, then identify the fix.  We typically did this by asking “why?” as many times as we could until we could no longer answer the question.  In our example where the wingman dies (simulated dies, of course!), it could have gone something like this:

 

“Why did #2 die on the ingress?” : His defensive systems were not set up correctly.

 

“Why were #2’s systems not setup correctly?” : He was behind on setting all his systems up because he was late getting to the jet and was rushed.

 

“Why was #2 late to the jet?: Because the flight lead’s briefing went 10 minutes long.

 

And there’s the root cause: #2 died because of something that happened 2 hours before the formation even took off: the briefing went long and jammed him, resulting in him missing things on his checklist.

 

The purpose of a good Root Cause Analysis (RCA) is to try and identify systemic issues and the associated remedies.  Too often, these analyses stop after the first “why?”.  

 

Why did #2 die?  Because he’s just not a good pilot.  The fix: stop sucking, 2! 

 

(But we know now, after our thorough analysis, that it was actually the flight lead who got him (simulated) killed!).  And we may have been able to back that analysis up one step further, perhaps the briefing time set by squadron policy didn’t allow the flight lead enough time to brief.  With that, you can make an organizational-level fix…now, we’re getting somewhere!  

 

The point of this segment is twofold: first, although we are oftentimes tempted to, in order to identify a root cause, you have to dig a little and invest a little critical thought.  Secondly, you can’t address a problem and come up with solutions until you’ve done your homework in step 1.  As humans, we like to check boxes.  We like easy answers and quick solutions.  A supervisor is harassing a subordinate?  Reprimand the offender.  Problem solved, begin hand-wringing!  The questions though, remain: what was the root cause of that harassment, and, most importantly, what have you done to prevent the next event from happening?

 

Let’s look at the DIA case as if we were in fighter pilots in “the vault”:

DFP: This former attaché (labeled “a disgruntled former employee” and liar by DIA leadership by the way) is going to the press and reporting all this stuff about DIA.

 

Let’s begin the debrief!

 

“Why is this Sweazey yahoo getting up in front of the national media and ranting about all the crap going on in DIA?” → Because he reported the issues to the Director DIA and nothing happened.

 

“Why did he go to the Director of DIA?” → Because he had reported the issues to the Director of the DAS and nothing happened.

 

“Why did he go to the Director of the DAS?” → Because he reported wrongdoing to his chain of command and was punished for it.

 

“Why was he punished for reporting issues to the chain of the command?” → Because that’s what they do in DIA.

 

“Why do they punish people who report wrongdoings?” → Because they can.

Translated: there is no one policing the police.  Who should be doing that? The office of the Inspector General.  Who isn’t doing it? The office of the Inspector General.

 

Root cause analysis, in full: If the DIA’s (and military’s) avenues of recourse functioned properly, they would have deterred, prevented and/or corrected past and present reprisal cases and averted the DIA scandal which is now ongoing.

 

At the end of fighter debriefs, we would offer up what we labeled “Instructional Fixes.”  They needed to satisfy two requirements: 1) they addressed the root cause(s) and 2) they were able to be implemented and repeated.  Returning back to our root cause: why could the DIA cabal operate with impunity?  Because the alleged “watchdog” of the Agency (the IG) was asleep on the job, consistently allowing it to happen.

 

Instructional fix: Repair the Department of Defense IG system.

 

And now you know why this Foundation exists.