Kevin Ian Schmidt Consulting

Tag: root cause

  • 5 Why Training – Root Cause

    5 Why Training – Root Cause

    One of the key business success factors that I have followed throughout the years is that of always trying to determine the root cause of any business problem. I focus on the root cause because anything less than that will not allow you to solve the problem completely.

    The reason that this is important is because most people only look as far as the symptoms that are causing the problem, not the root cause.

    There is an easy way to determine the root cause of a problem and it is called “The 5 Whys.”

    Many years ago the founder of Toyota Corporation, Sakichi Toyota, developed “The “5 Why” technique that was and is used within the corporation’s manufacturing methodologies. It is still considered a critical component of problem-solving at Toyota today.

    “The 5 Why” process is simply asking the question “Why” 5 times. Let me give you an example of only getting to the symptoms of a problem.

    -My car won’t start (the problem)

    WHY?

    -The battery is dead (the symptom)

    So the solution to the problem in this case is to recharge the battery. But the following week, you have the same dead battery problem. So you go to the auto parts store and purchase a new battery because the old battery apparently will not take a charge.

    However, the following week the new battery is also dead.

    So while you addressed the symptom of the problem, you really did not solve the entire problem because the battery continues to go dead.

    Check Out: The 5 Why Method of Root Cause Analysis
    If you are looking for assistance with completing a root cause investigation, I made a book to help you out, check it out on Amazon here

    Now. let’s take the same problem and apply “The 5 Whys” process.

    -My car won’t start (the problem)

    1. Why

    -The battery is dead

    2. Why

    -The alternator doesn’t work

    3. Why

    -The alternator belt is broken

    4. Why

    -It was worn and I didn’t replace it

    5. Why

    I was too lazy

    So the root cause as to why the car won’t start is the person’s laziness, not the dead battery. The dead battery is a symptom. The key is to urge yourself not to assume anything and to avoid logic traps. Instead, the solution is to follow the symptoms through “The 5 Whys” until you find the root cause of the problem.

    Often times, you will see that the root cause of the problem is not identified because you have a flawed process in place or no process at all. In this case you should be asking the question, what is the process that is in place, if there is one, and if so, is it the right process.

    In addition, a key phrase to keep in mind in any “5 Why” exercise is that people do not always fail. Sometimes process do.

    Identifying the root cause of any problem is critical to your success. Most people only identify the symptoms of a problem and then, after addressing the symptoms, wonder why the problem continues to reoccur.

    To facilitate better root cause analysis in the workplace, I published a Root Cause Analysis workbook available on Amazon.

    Download the 5 Why Method Training below:

    View the 5 Why Method Training below:

    5 Whys Training
  • Root Cause Worksheet

    Root Cause Worksheet

    Conducting a full and proper root cause analysis is important to completing an accident investigation. This worksheet will aid in a full root cause analysis.

    Including this form in your accident investigation toolkit, will aid those conducting an investigation after a safety incident.

     

    Using the Root Cause Investigation Worksheet

    Example Accident: “An employee comes into the lobby, with uncovered marble flooring during a rain storm, and slips on water puddled near door; spraining their wrist.”

    Even if this specific accident didn’t result in a serious injury, they can result in broken bones or head injuries. No matter the level of injury, each accident should be investigated equally to prevent future accidents that may result in a more serious injury.

    Using the root cause worksheet, you read the environmental section and see multiple applicable items.

     

     

     

    So, applying this to the above example, you can identify:

    • adverse weather: raining outside;
    • walking/working surface: uncovered marble floor;
    • poor housekeeping: water puddled at entrance on floor;

    as causes of this instance. So which is a root cause and which is a causal factor of the incident? You can find that by applying some simple questions:

    • If it were raining outside, and the floor was covered with an anti-slip rug, would this have occurred?
    • If housekeeping had cleaned up the water pooled, would the person have slipped?
    • If there was no puddled water, but the person’s shoes were slick with rain could they have slipped on the marble floor?

    Applying those questions, you will realize that the adverse weather and the poor housekeeping were contributing factors, while the walking/working surface was the root cause. Because a simple anti-slip rug could have stopped this, even if there wasn’t a puddle and it was raining outside, or if there was a puddle and it wasn’t raining outside.

     

     

     

    If you follow through with this root cause analysis, and take action and place an anti-slip mat at the lobby entrance, you have negated the possibility for further accidents.

    You can see how this root cause worksheet is a good tool to have as part of an accident investigation program.

    Ensure you give your team the tools and training required to fully implement a quality accident investigation program, which includes ensuring they are aware of their roles in the program, that they have been trained on their responsibilities, and they know how to follow-up to create change.

    I have also published a book for Root Cause Analysis, available in softcover and hardcover.

    Check out my book on Amazon.

     

    Check out the following related program components available for free:

     

    View the Root Cause Worksheet here

    Root Cause Worksheet

    Download the Root Cause Worksheet here

  • The 5 Why Method of Root Cause Analysis

    The 5 Why Method of Root Cause Analysis

    root cause 5 why trainingKnowing how to properly conduct a 5 why root cause analysis is imperative when handling a safety incident investigation.

    It isn’t just OSHA that encourages the use of root cause during an incident investigation, but also the EPA under their Risk Management Program(RMP).

    Concerning Root Cause Analysis OSHA says:

    During an incident investigation, an employer must determine which factors contributed to the incident, and both OSHA and the EPA encourage employers to go beyond the minimum investigation required and conduct a root cause analysis. A root cause analysis allows an employer to discover the underlying or systemic, rather than the generalized or immediate, causes of an incident. Correcting only an immediate cause may eliminate a symptom of a problem, but not the problem itself. – Source
    While this is not an official order to conduct a root cause analysis, and it may not result in an OSHA fine for not complying, it can potentially result in a violation of OSHA’s General Duty Clause:

    a) Each employer —

    (1) shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees;
    That is because the occurrence of a safety incident is a clear indication of a workplace hazard, and a failure to abate this hazard potentially means your company is no longer furnishing employees with a workplace with recognized hazards, as a full and proper root cause investigation would have uncovered the direct cause of this hazard.
    So while OSHA doesn’t require it, they may cite you over not investigating properly. Anyone with an understanding of OSHA rules, regulations, and interpretations, will understand this is often the case, as OSHA will always err on the site of caution for employee protection.
    Check Out: How to Improve Your Safety Culture

    The 5 Why Method as a Root Cause Analysis Method for Workplace Incidents

    The 5 Whys technique can also be used as a method for determining root causes of workplace incidents. What would 5 Whys look like in the context of a workplace incident investigation? Here’s the application of 5 Whys to an example mentioned in an OSHA fact sheet:

    The Problem: A worker slips and falls, and suffers an injury.
    1st Why: There was a puddle of oil on the plant floor.
    2nd Why: Oil spilled from a compressor.
    3rd Why: An oil leak from the compressor was not detected.
    4th Why: The compressor was not inspected on a regular basis and repaired (if required).
    5th Why and the Root Cause: The compressor was not in the maintenance system.

    In theory it takes five “whys” to get to the root cause, but in practice there will be cases where you may use more or fewer than five “whys”.

    This 5 Why Method Training will explain the basics of how to conduct a root cause analysis using the 5 Why method.
    Adding a 5 Why Method training to your company’s incident investigation training program will improve your accident investigations to best identify hazards in the workplace along with empowering your employees in owning their safety.

    Finally, according to the Washington State Department of Labor & Industries, these are the benefits of asking the 5 Whys:

    • Simplicity: Easy to use and requires no advanced mathematics or tools.
    • Effectiveness: Helps to quickly separate symptoms from causes and identify the root cause.
    • Comprehensiveness: Helps to determine relationships between various problem causes.
    • Flexibility: Works well alone and when combined with other methods.
    • Engaging: Fosters teamwork.
    • Inexpensive: A guided, team-focused exercise with no additional costs.

    Combining this training with the Root Cause Worksheet as part of your total incident investigation program will allow your team to thoroughly investigate every incident.
    Please check out the other components of an Incident Investigation Program, listed below:

     

    To facilitate better root cause analysis in the workplace, I published a Root Cause Analysis workbook available on Amazon.

    Download the 5 Why training

    View the 5 Why training

    5 Whys Training – Kevin Ian

     

     

  • Accident Investigation: Root Cause Analysis

    Accident Investigation: Root Cause Analysis

    Over the years, managers and leaders have written thousands of articles about the very complicated causes of accidents in the workplace. The consensus of opinion is that there is not normally one single cause of an accident or an incident. Instead, there are normally a combination of factors that contribute to the accident. These all come together under just the right circumstances to create an accident. Management thinking has moved on from the proposition that accidents just”happen.” But this has been replaced with a culture of blame.

    The problem of accident causation and prevention appears to be a hugely complex problem. However, some industries have proved beyond doubt that it is possible to prevent or control the causes of accidents. For most industries, it doesn’t require huge resources to be successful in preventing accidents and incidents.

    To better understand the circumstances that give rise to undesirable incidents, it would be wise to consider the four major elements that provide the source of accidents in the workplace.

    Elements of a Root Cause Analysis

    The first element is people. This includes everybody from the workers upwards. Its been well established that people are involved in a high percentage of incident causes. Normally, it’s the staff member that is the human element directly involved in an undesirable incident. What they do or don’t do is seen as one of the most common causal factors.

    The second element is equipment. This includes tools and machinery. Since we have been using tools and machinery, they have been identified as one of the major causes of incidents and accidents. Because of this they have been targeted by legislation that has made provision for machine guarding and training. The improper design of controls on machinery and equipment are frequently found to be the cause of many incidents related to safety quality and output.

    The third element is material. This is the stuff that people work with. Material can be sharp, heavy, hot or even toxic. Coming in contact with such things as explosives, chemicals such as solvents, dusts and noise can be a substantial source of undesirable incidents.

     The fourth element is the environment. This is all parts of the physical surroundings and include such things as the quality of air, lighting, heat, cold, humidity, fumes and even moisture. Increasingly, the environment is being identified as the cause of an ever-increasing number of diseases and health related conditions. It is associated with absenteeism and low work quality.

    Check out additional components of an Accident Investigation Program

    These four elements, to a greater or lesser degree, provide the source of causes that contribute to an undesirable incident. The investigation should include a scrutiny of one or all of these factors to pinpoint the cause of the incident or accident.  

    If you are looking for assistance with completing a root cause investigation, I made a book to help you out, check it out on Amazon here

     

    View & Download the Accident Investigation: Root Cause Analysis Training below

    Accident investigation_Root_Cause_Analysis