Reflections ... A Tale of Two 5-Whys
I trust our APM team members have seen the Red EHS Alert shared in our Weekly EHS Report – Week 6 regarding the recent pinched finger event. Fortunately, our APM teammate is recovering well and working.
We recently met with the investigation team to review the Root Cause Analysis (RCA) of the event. The team did a good job of gathering information, summarizing the event, and identifying the various causes. One tool the team used to discover the root cause is a 5-WHY Analysis.
Attached is the Initial 5-WHY the team conducted. After reading Questions 1-3, I bring your attention to Question 4.
4. Why did it hang up on the scaffold component?
• Answer: Gap was not identified during hazard assessment prior to the task.
The answer to Question 4 is a Human Performance answer, i.e., our employees did not identify the hazard. This led to Question 5 being focused on a further Human Performance answer, poor communication.
While discussing the 5-WHY with the team, we asked, “What if we answer Question 4 differently? How would that affect our answer to Question 5?”
4. Why did it hang up on the scaffold component?
• Not: Gap was not identified during hazard assessment prior to the task.
• Replace with: There was a gap present prior to completing the task.
5. Not: Why was it not identified? Replace with: Why was the gap present?
• Answer: The scaffolders did not close the existing gap between the components before releasing for use.
WHY (pun intended) did we ask the team to answer Questions 4 & 5 differently?
In every accident there is always a Human Performance error – a human made a mistake. As much as we try, we will never eliminate human mistakes. “To err is human.” While we can and should learn from human performance error, and take actions to correct and prevent human error (ex: refresher training on STA and 3-Way Communication), we will not get to 100% safety by only focusing on correcting and preventing human performance error.
Thus the second 5-WHY. By answering Question 4 with a “system” or “design” answer (ex: the work environment had a scaffold gap present), we now focus our attention on how we (the system that designed the work environment) introduced a hazard that placed the employee in a position to be hurt when human performance error occurred. If we then learn from the system / design error, and take action to improve the system / design, we remove the hazard and thus negate the affect of human performance error. Stated another way: If there is no scaffold gap, there is no pinch point and thus no finger injury. Correct the gap, design the scaffold better, and the hazard recognition / poor communication errors don’t become a finger injury.
We will continue to focus heavily on Human Performance to sustain our safety excellence and steadily reduce injuries in the field. You already see that this spring with our weekly HOP & SET reminders. But I am convinced Human Performance will only take us so far. Again, we cannot create perfect humans who never make mistakes. Thus, when an injury occurs, I am committed to focusing more on the systems and designs, i.e., the work environment, to eliminate hazards.
— Jake