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Loss of Control Root Cause Model

View the Full Loss of Control Root Cause Model

This Loss of Control Root Cause model captures the large range of reasons why fatalities occur in general aviation, as well as their interrelationships. The purpose of this model is to articulate the full extent of the loss of control (LOC) challenge, and therefore to present all of the areas for innovation to solve this problem. 

The model was developed by a team of aviation and industry experts to put a comprehensive picture before the aviation community. The team does not claim that the model is perfect, but rather we hope that close study of it will spark a multitude of innovative ideas that will work together to reduce and eliminate LOC fatalities in our community. We fully expect that the model will evolve over time.

How to Read the Model
Each box (except the two pink ones on the left side) in the model presents a reason for the occurrence of LOC events. The model flows from top to bottom roughly in the sequence of an LOC event, beginning with preconditions and risks, through pilot culture and behaviors, pilot failures, aerodynamics of stalls and spins, ineffective recovery, and finally impact with the ground.

The boxes are interconnected with arrows that show logical links between them. To read the model, start with any box and follow the arrows emanating from it to the right side of the model while asking the question "why does this happen?" The box or boxes connected to the right answer that question. 

Where multiple arrows depart a box to the right, this denotes that there are multiple potential reasons why the problem occurs. In other words, if two arrows depart to the right of a box to two different boxes, then the reason for that is either one OR the other of the two boxes to the right. In some cases, an AND link is shown connecting two or more boxes to the right. This means that both (or more) of the boxes to the right together are reasons for the problem.

The significance of the OR and AND links is critical to innovation. If for example two arrows are connected with an AND link, then only one of the two problems needs to be solved to eliminate the root problem. Conversely, if arrows are not connected with an AND link, then all of the problems need to be solved to eliminate the root problem.

Finally, the boxes in the model are color-coded into themes to assist the reader. The six themes and their color codes are shown in the top left corner of the model.

Questions or Comments
Contact the EAA Advocacy team at foundersinnovationprize@eaa.org.

Loss of Control Root Cause model
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