…How to Focus on the Real Root Cause of Errors

Maya NikolovskiSafety managementLeave a Comment

Why imageThe next blog in our series on how to develop a Behavioural Based Safety System is ‘How to Focus on the Real Root Cause of Errors’ – We don’t like to make things complicated and think you’ll find this a really easy model to follow. Try it out and do please let us know how you get on?

Determine the Root Cause by asking ‘Why’ five times…

We certainly don’t want to make you sound like your five year old child by constantly asking ‘Why?’ the whole time, but it is a great tool to use to drill down into an issue and find the ‘Root Cause’ of a problem or failure. If you repeatedly ask the question ‘Why?’, just as with an onion, you can strip away the layers of symptoms to allow you to find the root cause of a problem. We recommend asking ‘Why?’ five times, but in truth you may find you need to ask this question more than that or sometimes less, but five times is a good ‘Rule of thumb’. If you do this, you’ll find that the answer to one question will naturally lead you to ask the next and so on.

What are the benefits of asking ‘Why?’ five times?

  • To help identify the root cause of a problem
  • To find if there’s any relationship between the apparent causes of a problem.
  • It’s simple and doesn’t need complicated statistical analysis.

When should we ask the five ‘Why?’s?

  • Whenever an issue involves the ‘human factor’ or the involvement of people, or
  • At any time in the course of operations. It can be done quickly and easily.

How should we ask the five ‘Why?’s

  • Write down the nature of specific problem or issue you’re reviewing. This helps you and your colleagues collectively describe and understand the problem together
  • Ask why the problem arises and then just write down the answer beneath the problem
  • If the answer to ‘Why?’ doesn’t identify the root cause of the problem then ask ‘Why?’ again and write that down, and so on
  • Keep going and asking ‘Why?’ until everyone agrees that the root cause of the problem has been identified.

Here’s an example: Let’s assume that your major client is unhappy because the products that you’ve just delivered don’t meet the agreed specification – you’ve got a major problem and risk losing the client to a competitor if you don’t come up with an answer quickly… Firstly, write down the ‘Problem Statement’: Our customer is upset because they’ve received 10,000 widgets that don’t meet the agreed specification.

1. Why has the customer been shipped defective widgets? – Because we fabricated the widgets to a different specification that that which was agreed.

2. Why did we fabricate the widgets to a different specification than that agreed? – Because the production team took instructions from sales over the telephone and they misunderstood the requirement.

3. Why did sales call the production team instead of following the procedure established in the QA system? – Because the ‘start work’ instruction form requires both the sales director’s and the production director’s written agreement before work can begin. This was going to slow the manufacturing process as the Sales Director was travelling overseas at the time.

4. Why does the form specify that BOTH the Sales and Production Director’s written approval is required? – Because the QA manager specified it when she designed the form

5. Why did the QA manger specify that BOTH approvals were required in WRITING? – Because the same problem has arisen before when Production were told to do something verbally by Sales that had never been approved. The business had previously lost a customer as a result of the specification being communicated improperly.

In this case we have asked ‘Why?’ five times to find out that the apparently urgent requirement for a written signature authority helped to cause a process breakdown. As you can see the final ‘Why?’ leads the team to a statement (a.k.a the ‘root cause’) so that the team can now take action and do something about. In this case it was a matter of ‘more-haste-less-speed’ and it would have been much quicker and less costly to define a secure system that keeps the sales and production directors informed than it is to try to directly solve the apparent problem (a rush order) without proper thought and planning.

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