“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
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
- Why is work phase A always rushed? Answer: Customers ask for information about service A by phone more than usual.
- Why do customers ask for information by phone more than usual? Answer: They cannot find the information they need from the online service.
- Why can’t they find the information they need from the online service? Answer: Service A is described too narrowly in the online service.
- Why is service A described too narrowly on the website? Answer…
Example B: Investigating an occupational accident
- Why did the employee fall? Answer: There was a patch of oil on the floor of the workspace.
- Why was there a patch of oil on the floor of the workspace? Answer: One of the machine’s seals had cracked, allowing oil to leak onto the floor.
- Why did oil leak onto the floor? Answer: The material of the seal was not strong enough for the intended use of the machine.
- Why was the seal’s material not strong enough? Answer: …
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.