Vital Incident Questions: The 5 Whys

[Image courtesy of Flickr user Jan Tlk via a Creative Commons license]

Those Tough Questions

We can all admit that “how” and “why” are indeed tough questions to answer honestly when investigating an incident on your worksite. But we also can agree that taking a narrow approach to finding a single root cause for an incident can be counterproductive, and in fact might even be dangerous in terms of future incidents.

In order to do ourselves justice, we have to take a long look at the investigative models we’re using and consider using one that is more effective at taking a macro view of an incident to account for every aspect of the incident, not just the immediate actions that caused it.

I have been digesting and processing Fred Manuele’s May 2016 article in Professional Safety magazine that attempts to get us all to see incident investigation with clear, unbiased eyes and help understand the context that goes into an incident and challenge us to embrace the possibility that our very own safety protocols and system deficiencies or failures may impact incidents, and we have to be willing to face ourselves in the mirror if that truth reveals itself in our investigation.

The Five Whys

One of the ways to get a the truth, even that which is hard to accept, is to start asking questions And in order to answer the overlying “how” and “why” questions of an indent, we often have to suck it up and ask very specific questions in order to better understand an incident better and whether it is something we can mitigate with existing systems or if changes are needed.

One technique is called the Five Whys. Manuele covers it with a whole section of his article, describing it as an effective means to getting to an answer when looking at an incident. Wile many may consider it too simple, sometimes the best techniques are those that aren’t complex. The point is to get an answer and have that be the objective, not about how complex a technique is to get the answer we need.

The Five Whys technique is simply a technique to ask a series of “why” questions about specific items that are to be considered in a incident. Manuele provided three case-study examples of how the Five Whys technique is used in incident investigation.

The concept is pretty simple – you start with a simple “Why did this specific event occur?” and you move from there to ask “why” about each particular aspect of the incident, leading down the chain of actions that ultimately led to the incident.

As an example, in one of the case studies Manuele featured in his article, the technique was applied to an incident involving a wheeled cart that tipped over, injuring a worker seriously. The first question as, “Why did the cart tip over?” When the answer came back that the casters used to wheel the cart were too small for the cart, the next question that was asked was, “Why is the diameter of the casters too small?” When that answer was “They were fabricated that way,” the next questions was, “Why did the fabrication shop make casters that were too small for the carts?” The next answer was, “They followed directions set forth by engineering. ”  This resulted in six actual “why” questions (five is a guideline; sometimes you only need four, sometimes six or more) to finally come to a determination that those who made the casters did not consider the hazards of the cart tipping over due to the size of the casters. This technique resulted in changes to how the casters were made so the tipping-over hazard would be addressed in a short timeframe, mitigating the risk of tipping incidents in the future.

If you can construct at least five “why” questions for your investigation, you will go a long way toward addressing the contextual causes for the incident and be able to find the areas where proper action should take place so the incident doesn’t happen again.

And there are no such things as stupid or obvious “why” questions; they all need to be asked, or an accurate “how” or “why” cannot possibly be gathered and understood. And when that doesn’t happen, workers remain at risk because we end up not learning anything.