The Five Whys (Y5th)
Finding Root Causes in SMS (Safety Management Systems)
On September 17, 1908, Orville Wright and Lt. Thomas Selfridge got into the Wright 1908 Flyer as part of the War Department proving test for the airplane. After the third lap of the Ft. Myers parade ground, Wright heard a strange “thumping” sound, but he could not identify the problem. Eventually, he lost control of the plane and it crashed. Selfridge was killed and Orville was severely injured. The post-accident investigation, such as it was, determined that the crash was caused by a stress crack in the propeller. A redesign of the Flyer’s propeller eliminated the flaws that led to this accident. That was the first fatal accident in aviation (there were many deaths prior to 1908, but the Wright Brothers aircraft was the first heavier-than-air, controllable in three dimensions vehicle, thus the first airplane.
The techniques of the NTSB and commercial aviation (operators and manufacturers) have developed an iterative rubric of tremendous sophistication and integrity.
However, SecurityIntelligence published an interesting article about investigative techniques which may stimulate a discussion of what works in finding root causes in SMS; it is:
Here are the major premises of the article:
- “In his 2008 book ‘Outliers,’ Malcolm Gladwell explored the lessons that can be drawn from studying aviation disasters, seeking to shed light on the root causes of some major crashes. The work, firmly grounded in the Federal Aviation Administration’s (FAA) Human Factors Analysis and Classification System (HFACS), pointed to the breakdown of communications inside the cockpit at key moments in the flight as a major source of human error, eventually leading to a perfect storm of factors contributing to a crash.”[i]
- “After an incident, it is tempting to blame someone, as was too often done in FAA crash investigations: ‘Unfortunately the root cause analysis of an accident often stops after the simple finding of “failure to follow procedures.” This failure goes far beyond a “lazy mechanic” who chooses to be noncompliant.’”
- “The Five Whys is a method of exploring cause-and-effect relationships. This technique can be used as part of a root-cause analysis to uncover ways to avoid future incidents. When applied to recent near misses, it can help prevent future events from turning into full-blown disasters.”
- “The Five Whys technique helps investigators and analysts determine the root cause of a problem by repeatedly asking, ‘Why?’ Investigators are cautioned to use deduction, to focus on processes and not behavior, to avoid jumping to conclusions, and to focus on causes, not symptoms.”
- “The Five Whys technique can help foster a sound and systematic approach to investigating both incidents and near misses. It puts the organization on a path to continuous self-improvement and provides improved clarity about just how efficient its security controls truly are.”
The ultimate source of the Five Whys (Y5th) is a paper written by Olivier Serrat, a principal knowledge specialist (B.A. University of Kent, M.Sc. University of London). His article has been cited by iSixSigma, QualitySafety.com, SAE (in an aviation treatise) and a large number of reliable publications/scholars/experts. [Not sure if this is a definitive list.]
Serrat added some illustrations to demonstrate the value of Y5th technique:
- Has anyone incorporated the Y5th approach to their SMS work?
- Has the Y5th technique proved useful?
- Or not—please let us know?
- Has anyone used the principles of The Undoing Project by Michael Lewis which defines improved decision-making?
- Any other useful approaches in your SMS work which have been useful?
These interesting techniques are posted to stimulate discussion among the SMS participants. PLEASE, PLEASE, PLEASE submit comments of Y5th, The Undoing Project or any other regimen which sharpens the search for root causes.
[i] Gladwell’s best seller ‘Outliers” is also the source for the aphorism that 10,000 hours of practice is a universally applicable measure to become a master in all fields of endeavor. Unfortunately, the author of one of the studies which Gladwell cited, Anders Ericsson and Robert Pool, disagreed. Gladwell over extrapolated their findings beyond their subject group, violinists. This is being noted to put into question non-scientific truisms.Share this article: