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“Discussion about accidents or near accidents easily drifts into who is to blame and who hasn’t followed the instructions. How could I steer the conversation so that we get to the root causes?”

Topic: finding the root cause of an issue or problem in its current state, investigating an occupational accident, processing a safety observation

Time required: less than 10 minutes, no time-consuming preparation required

Materials: paper and a pen; flip chart paper and a marker in a larger group

Method description

Define the subject together, for example, rushed work phase A or safety observation B.

Ask the following five times in a row: Why did this happen? Emphasise that the goal is to find the root cause of what happened, instead of finding someone to blame. Ask the pairs or the group to write down the question-and-answer chain. Alternatively, you can also do this yourself.


Example A: Rushed work phase

Example B: Investigating an occupational accident

Note that five rounds of questions are not always needed to find the root cause of what happened. Sometimes more than five rounds may be needed. The question-and-answer chain is continued until the real cause of the issue or problem has been found.