Hi,

I have been asked to complete an investigation into an incident whereby an FLT's mast hit a roller shutter door causing extensive damage to the fabric of the building.

I loath to put in operator error and close the investigation there. From the info I am gathering thus far the person involved in the incident said he felt under pressure to keep a production line running and his shift was a man down consequently he was rushing here there any everywhere, the person has never had a bump on his FLT in 15 years  service etc....

Could anyone advise on the best type of investigative tool to find indirect causes? I struggle with the Five why concept I struggle to get to five whys and tie myself in knotts.

Are there any good websites out there explaining the methodology or other useful investiagtive tools?

Thanks

The HSE have a comprehensive accident investigation guide which provides a framework for using "WHY" questions and suggested formats for the report.

See http://www.hse.gov.uk/pubns/books/hsg245.htm

It may assist you identify the reasons why the driver was rushing without apportioning the blame as driver error.

I agree with PL53 5 Whys is just a name - sometimes you need 5 million whys and sometimes only one or two.  I often use the 5 whys technique to gather information and then fishbone to organise it so that I can work with it.  Its all about understanding the story of the accident - what happened before the event to set the scene for the accident to happen and then the accident itself and finally the aftermath.  I sometimes use mindmaps, rich pictures and word cloud techniques too to help me to link and relate each bit of information together.  It isn't a matter of picking a technique and sticking to it exclusively its about finding a mixture of approaches which enables you to understand exactly what happened and why it happened and most importantly to understand why people do the things they do.  Operator error is a cop out people don't set out to make mistakes, circumstances combine to lead to the mistake and the consequence.  For what its worth I think the HSE approach is too rigid and mechanistic - the principals are sound but they don't help you to truly understand what happened, its just all about getting the facts and not understanding all the other factors.

Peter this is a very good point the design of the roller shutter door supports were badly designed.

Two brick pillars supporting a piece of  reinforced contrete that weighed in excess of 6 tonne to which the roller shutter doors were attached.

The doors were 20 years old too and there had been several near misses

As you say the Five WHY’s is just a technique for accident investigation and to be honest I have in 15 years never used a formal system to investigate an accident. Instead I have tried to get down to what we like to call the Root Cause. There are 5 whys because that is generally seen as been the right depth of investigation that gets you to some form of management failure as the root cause eg POOR MAINTENANCE, POOR PLANNING , POOR BEHAVIOUR .  Anything less than 5  you end up at the operator error sort of conclusion which does not give much opportunity for improvement ( other than sacking the operator) or if you go too far 20 or 30 whys’ you can disappear into the realm of philosophy, metaphysics or thermodynamics.

The highly structured approach can make sense if you are investigating the failure of a part or a system but are less use when dealing with the human factor.

Edited by user 22 February 2018 15:00:13(UTC)  | Reason: If I could spell I'd be deadly

Originally Posted by: Kate

You are right not to say 'human error' and leave it at that. I recommend the classic HSG48 'Reducing error and influencing behaviour' which shows how to analyse and classify human failures. 

http://www.hse.gov.uk/pubns/books/hsg48.htm

HSG 48 is very good starting point for getting your head around accident investigation.

Each Why does not necessarily have a single answer so like the fishbone you may branch in different directions

Along each presented path ask Why until no answer appears (5 is just guidance)

You will likely end up with a web of contributory issues, and as you correctly identify not just "operator error"

The real skill is inversing this process to derive a comprehensible action plan for management to execute

I would suggest that 5 Whys and Fishbone are not investigation methods.  They are tools to analyse incidents after you have done your initial investigation.  As with all tools, you need to use the right one for the right job, and you may need to use more than one to complete the job at hand.

You may find this useful for causal trees (same idea as 5-whys).