Five Whys II
The Internet, if it is to be believed, tells us that the prime purpose of the 5-Why approach is to determine the Root Cause(s) of a problem. The implication of this, and other similar approaches, is that the intervening steps - the other so called 'causal factors' - are not particularly important.
We are not sure this is wise for two very significant reasons:
1. The Root Causes, by 'five-why' definition, are five steps away from the incident itself. So, fixing the Root Cause is no guarantee that the same incident will not happen again, because it is too far removed from the incident.
2. Fixing Immediate and Underlying Causes can be quick and easy, and can have a very powerful and significant effect. Consequently, they should never be ignored.
This is much better illustrated using specific examples. So, let's look back at the incident described in our last News Item (http://www.kelvintopset.com/blog/why-fives), where a young girl drowned in a garden pond. The Root Cause was the careless attitude of the parents. If we re-educate the parents can we be sure that another child of theirs will not drown in the pond? It seems very likely, given the gravity of the event, but we cannot be absolutely certain.
However, if we put a grid over the pond then we can be certain that same event will not happen again with their child, and better, any other child who happens to be playing in the garden! We have fixed an Immediate cause and ensured that the same incident will never happen again. Was that worth doing? We think so.
So the Kelvin TOP-SET approach is to analyse every event thoroughly, using as many 'whys' as required, and looking at all the causes which contributed to the event: the Immediate Causes, the Underlying Causes and the Root Causes. Once complete, we then consider controls, barriers and defences at ALL levels of the analysis, not just the Root Causes.