The “5 Whys” accident investigation technique offers a structured and simplified approach to uncovering the fundamental cause of failures and mishaps. Accident investigations can often feel like navigating through a maze of symptoms and effects. The 5 Whys technique provides a clear and linear path to the root cause, ensuring that no stone is left unturned. Throughout this blog, we will explore how to effectively apply this technique, discuss common pitfalls, and share tips and tricks to maximize its impact.
The Impact Of The Root Cause
In the project management world, project recovery comes down to identifying the root cause of the failure and taking the necessary steps to correct it. Although a root cause analysis will often uncover many red flags hidden throughout multiple levels of the project, these issues can often be residual symptoms spurred by the root cause. Think of the root cause like a poison that seeps into other areas of the project. For example, project derailment will commonly create demotivation and confusion among team members, leading to late completion of deliverables, or low quality execution. The quality and late completion of deliverables is definitely a problem that affects the project, but it’s actually just a small piece of the puzzle that forms the larger problem, or root cause, of the project’s failure.
The root cause may be less clear, and harder to correct in situations where accidents have occurred. Ideally, we want team members to feel comfortable enough to candidly disclose blunders both big and small, as soon as they occur, but that might not always be the case. Team members may worry about the consequences, so much so that they stay silent or feign ignorance. This is exactly why establishing comfort and trust during the project’s early stages is vital. On the other hand, many accidents can occur without awareness.
What’s important to acknowledge is that accident investigation is not a matter of finding who to blame. Finding the team members directly involved in the issue is still key to the process, but not the goal. The main goal of a slip-up investigation is to determine what caused the problem and strategically correct the problem in a way that ensures it doesn’t reoccur.
Understanding the 5 Whys Technique For Accident Investigation
The 5 Whys technique is a simple, yet powerful tool for uncovering the root cause of problems, particularly in accident investigations. Originally developed by Sakichi Toyoda, the founder of Toyota Industries, this iterative interrogative technique involves asking “Why?” five times or as many times as necessary to pinpoint the underlying cause of an incident. This method is especially effective for projects with large amounts of collateral damage. It allows facilitators to first pinpoint a smaller problem or symptom and dig deeper into the larger problem with each “Why?” that is answered.
How the 5 Whys Technique Works
- Identify the Problem: Begin by clearly stating the accident or issue that occurred. This provides a focused starting point for your investigation.
- Ask “Why?” the Problem Occurred: This step involves asking the first “Why?” to determine why the problem happened. Record the answer.
- Ask “Why?” Again to the Previous Answer: Using the answer from the first “Why?”, ask a second “Why?” to dig deeper into the cause. Continue this process.
- Repeat Until the Root Cause is Identified: Typically, this process is repeated five times, given the term ‘5 Whys’, but facilitators should keep the conversation going as needed, until no further answers can be derived or the cause seems to be fundamental. Each “Why?” should bring you closer to the root cause.
Example of the 5 Whys in Action
Scenario: A team member accidentally deleted essential code needed for engineering a new app the company is developing.
Q: Why was the vital code deleted?
A: The team member mistakenly thought that the code was an obsolete version and deleted it.
Q: Why did the team member think the code was obsolete?
A: The file naming and version control systems were not clear, leading to confusion.
Q: Why were the file naming and version control systems not clear?
A: There was no standardized naming convention or a well-documented version control protocol in place.
Q: Why was there no standardized naming convention or protocol in place?
A: The team had not prioritized establishing these conventions due to tight project deadlines.
Q: Why were project deadlines prioritized over establishing essential protocols?
A: There was pressure from upper management to deliver the app quickly, leading to shortcuts in setting up best practices.
The root cause of the accidental deletion of vital code was the absence of standardized naming conventions and version control protocols. This occurred because the team prioritized meeting tight project deadlines over implementing necessary best practices. Now that the root cause has been identified, the solution is clear. The issue can be resolved through the implementation of a robust version control system, such as Git and establishment and enforcement of a standardized file naming convention. Project managers can provide training to all team members on the new system and protocols, and schedule regular random reviews to ensure adherence to these conventions. By addressing these root causes, the company can minimize the risk of similar incidents in the future and improve overall project management practices.
The 5 Whys has a simplistic nature that makes it incredibly easy to adopt and start using. It requires no advanced tools or statistical analysis, and prevents addressing symptoms rather than underlying issues. Its versatility makes it applicable across various industries and various types of problems with effective communication.
Applying the 5 Whys in Accident Investigation
The 5 Whys technique is an invaluable tool for uncovering the root causes of accidents, allowing organizations to mitigate risks and prevent recurrence. However, to apply this method effectively, it’s essential to follow best practices and be aware of potential pitfalls. Below are tips and tricks to maximize the effectiveness of the 5 Whys approach, along with common mishaps that can occur and strategies to avoid them.
Tips and Tricks for Applying the 5 Whys
- Be Visual and Tactile: A great tool to use is an Ishikawa (Fishbone) Diagram on a whiteboard where each team member can add to the diagram as they explore. Place the problem statement at the “head of the fish” and use each “bone” to explore various causes and sub-causes under headings like people, resources, process, system, environments etc.This creates a collaborative graphic record as the team progresses. It also eliminates any confusion with regards to perception, meaning or interpretation.
- Clearly Define the Problem: Ensure that everyone involved fully understands the incident you are investigating. A well-defined problem statement sets a clear direction for the analysis.
- Involve the Right People: Include team members who have direct knowledge of the process or activity where the problem occurred and where the consequences were felt. Their insights are most vital to uncovering the root cause of the accident.
- Be Specific and Objective: When asking “Why?”, be as precise and objective as possible. Avoid assumptions or opinions and focus on factual information.
- Establish Trust and Transparency: The 5 Whys require complete transparency from the individuals answering. Dishonesty will allow the problem to remain hidden and unclear, which becomes a barrier to problem-solving.
Common Mishaps and How to Prevent Them
- Stopping Too Soon: Frequently, teams stop asking “Why?” prematurely, resulting in addressing symptoms rather than root causes. Be persistent and thorough. It might take more than five iterations of why to discover the true root cause, but the train of thought must be exhausted.
- Focusing on Individual Blame: Blaming individuals rather than examining systemic issues is not conducive to creating a safe place and can derail the investigation as well as reduce team cohesion and morale. Focus on processes and systems, not individuals. Use “we” and “us” instead of “you” to ensure no particular person or team feels ostracized. Create a culture of continuous improvement rather than blame.
- Assuming Single Root Cause: Assuming there is only one root cause can lead to incomplete solutions. Be open to the possibility of combinations of multiple root causes that may even be dependent on each other. Address all identified factors comprehensively.
- Overlooking Contextual Factors: Ignoring the broader context, such as workplace culture or external influences, can lead to incomplete analysis. Consider the environment, organizational culture, and external factors that could have contributed to the problem.
- Lack of Follow-Up: Failure to follow up on corrective actions can result in recurring issues. Implement a review process to ensure that corrective actions are completed and effective. Monitor the situation to verify that the problem does not reoccur. This also demonstrates to the team that it is worth investing time in root cause analysis.
Conclusion: Building a Resilient Foundation with the 5 Whys Technique
The “5 Whys” accident investigation technique serves as a cornerstone for identifying and addressing the root causes of accidents and operational failures. Its simplicity, adaptability, and focus on systemic issues over individual blame make it an indispensable tool for continual improvement. By meticulously applying the 5 Whys and following best practices, organizations can uncover the deeper, often hidden, issues that lead to setbacks and develop robust corrective actions to prevent them from reoccurring. Teams elevate in performance and motivation as they experience the advantages of breaking the issues down in a quick, impartial, clinical, and objective manner and, more importantly, seeing remedies they have formulated being implemented successfully. The engaging, participative nature of the exercise stimulates greater ownership, stewardship and buy-in.
Embracing the 5 Whys technique ensures that solutions are comprehensive and that improvements are sustainable. By fostering an environment of transparency, collaborative continuous improvement, and systemic analysis, organizations can not only resolve current issues but also build a resilient foundation for future success.
Valstroom has helped dozens of organizations build the foundation for sustainable project execution and delivery. We are the first responders when it comes to complex project execution, whether it be a project in need of refinement or a sinking project in need of a life line, we’re right by your side. Contact us for immediate project support today.