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Prevent problems from growing: the Grenfell Tower fire

Posted on: June 25, 2017

Working to mitigate the magnitude of issues By Holly Maher The current count of those missing and presumed dead from the Grenfell Tower fire on June 14, 2017 stands at 79. A large fire ripped through the 24-story residential building located in west London in the early hours of the morning. Whenever an incident of…

Don’t let unintended consequences bite you

Posted on: June 17, 2017

Unintended Consequences By Kim Smiley Once an incident investigation is complete, the goal is to use the lessons learned to develop and implement a solution that reduces the risk of the issue reoccurring. It’s a straight forward concept, but even with seemingly simple solutions, things don’t always go according to plan. The Cobra Effect Have you…

What is a 5-WHY?

Posted on: June 10, 2017

What is a 5-Why? Don’t complicate this simple tool  By Mark Galley 5-Why is a problem-solving tool that starts with a problem then asks a series of why questions. The first question is “Why did this happen?” The answer to that question becomes the basis for the second why question which is again, “Why did…

Holes in the Swiss Cheese Model?

Posted on: June 2, 2017

How to leverage the strengths and weaknesses of the Swiss Cheese Model of Accident Causation  By Aaron Cross The Swiss cheese model of accident causation developed by James Reason provides an excellent visual representation of how a high severity problem is comprised of a system of breakdowns within an organization. It has gained popularity as…

Headaches Into Heart Attacks

Posted on: May 26, 2017

Don’t Turn a Headache into a Heart Attack The Response to a Problem Can Create an Even Bigger Problem  By Mark Galley Companies sometimes make a problem worse by how they respond to it.  The initial problem wasn’t good, but now the consequences are even larger.  Some people refer to this situation as turning a…

5 Tips for Creating an Effective Executive Summary

Posted on: May 18, 2017

How to use a Cause Map to clearly summarize an investigation  By Kim Smiley When making an executive summary, you are trying to summarize a large amount of information as concisely and clearly as possible. They say a picture is worth a thousand words, so what if instead of just writing sentences in an executive…

When is an investigation done?

Posted on: May 11, 2017

Learning when to stop digging  By Kim Smiley Many people are familiar with the concept of root cause analysis and the idea of digging down to identify the root of a problem, but one question that we get asked over and over is how deep should the investigation go? How many “why” questions are enough?…

The Force was NOT with Them! Episode 2

Posted on: May 3, 2017

The story of a roguish design flaw  By Jon Bernardi (Spoiler alert – if you have not seen Rogue One, this Cause Map reveals the surprises.) Last year we presented, against the wishes of the Emperor, a Cause Map investigating the destruction of Death Star One (DS-1). (See the Cause Map posted not so long…

Using a 5-Why to Start Your Root Cause Analysis Investigations

Posted on: April 20, 2017

Would you like to learn more about how to effectively use 5 Whys? The 5-Why Approach | ASQ World Quality Conference Please join us at the ASQ World Conference on Quality and Improvement in Charlotte, NC on May 1. Mark Galley will be presenting “5 Whys: How to Fully Utilize a Powerful, but Confused Tool.”…

Rocking the Baby

Posted on: March 31, 2017

When the bough breaks, the cradle will fall?  By Jon Bernardi As much as we thought we had reduced the risk of injury to small children, there has been a most disconcerting issue rearing itself. It has come to our attention that some parents are placing their children in boughs, of all places, resulting in…