Advanced Safety Management, 3rd Edition

CHAPTER 21THE FIVE WHY PROBLEM-SOLVING TECHNIQUE

As has been said previously, the quality of incident investigations, even in some very large organizations, is significantly less than stellar. Yet incident investigation is a vital element within an operational risk management system. For a first step forward to improve on incident investigation, I promote adoption of the Five Why problem-solving technique, with emphasis. Why do so?

1. There is a substantial need for a causation model that is relatively easy to learn and apply. Application of The Five Why System does not require: extensive and costly training and retraining, the use of advanced mathematics, or overly complex methods.
2. If successfully adopted, The Five Why System would:
   • Be a major step forward to improve the quality of investigations;
   • Lead to the reality of systemic, risk-based causal factors;
   • Assist in noting the absence, inappropriateness, misuse or nonuse of barriers that should have been in place and properly used; and
   • Provide risk-related data to determine when risk assessments should be made.
3. Because of its structure, The Five Why technique promotes:
   • Involvement of individuals in the investigation group who are close to the work;
   • Critical and systematic thinking; and meaningful discussion to lead to agreed-upon risk-related causal factors and the preventive actions to be taken.
4. Use of The Five Why technique helps determine whether the causal factor chains are of such complexity that other incident investigation ...