Accidents happen, as any parent will tell you, and we are often left wondering why. A critical component of accident investigation is getting to the “why.”
A child asks “Why?” to which we generally answer “Because”, only to be asked “Because Why?”. Everyone who has young children has been engaged in this exercise – and while it may seem circular at face value, the child is only investigating an observed action or condition in order to understand the truth and its rationale.
Successful accident investigations – particularly when trying to correctly identify the basic or “root” cause – should employ a similar strategy. In reality, investigations typically do not evolve beyond the investigators’ interpretation of an event as told to him by those involved. Further, the investigators’ conclusions are rarely tested for their validity and often do not address the real cause – resulting in the possibility of another identical accident occurring.
Although there are several cause/effect and failure analysis systems utilized in industry, these models were created primarily for quality control purposes are are often forgotten or overlooked as value‐added tools for use in an accident investigation. The 5 Why method, perfected by your child, is often vastly superior.
The 5 Why approach is one of the simplest methods of causation modeling and doesn’t require any knowledge of statistical analysis.
The 5 Why approach is one of the simplest methods of causation modeling and doesn’t require any knowledge of statistical analysis. If you can ask “Why” this model will work for you.
In addition to being simple, it can capture problems involving human factors and interactions that other systems cannot. 5 Why will also assist you in determining the relationship between different root causes of a problem.
So how do you use it? First define the problem or resulting condition of the accident. Write this statement down, so that all personnel involved in the investigation will have a clear understanding of the outcome being investigated. Next, ask the question Why did this happen, and write down the answer. By documenting the answer, anyone can later review and recreate the thought process and causation. If this doesn’t get you to the root cause, ask Why again. Subsequent Why conditions can be directed at either the problem statement or to further investigate Why responses. Continue this question and response process until the investigator(s) agree that the root cause or causes have been identified. Generally, asking five Why questions down any line of reasoning should provide an actual method of cause – give or take a Why or two.
Continue this question and response process until the investigator(s) agree that the root cause or causes have been identified.
So next time your child asks “Why?” see if you can get to the answer in five exchanges. It’s fun, it’s
educational ‐ and it’s a much better game than “Are we there yet?”.
Patrick Smale, President