5-Whys An Introduction Part 2 1.0

[Bev D]

Bev D submitted a new resource:

5-Whys An Introduction Part 2 - General approaches to performing a 5-Why investigation

This part describes the approaches of direct observation and objective evidence, how to structure questions that can be answered, how causal systems actually work and how to decompose them in a progressive adn convergent manner.

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[Tidge]

Thanks for this!

My initial reaction is that I found some of the examples to be slightly distracting from the methodology, even as they illuminate (causal) chains of events. When I'm teaching material, I may introduce a couple of examples early, but then plow through using one that was introduced. Occasionally I circle back to an earlier (unexplored) example, working it "quickly" to demonstrate the method for more than one case (for student reference).

For better or worse: I would drop the "police investigating the scene of a crime" analogy. Too often the narrative of "police action" becomes complicated, and there is a LOT of evidence (outside of television and movies with detectives as protagonists) that police investigations don't have "problem solving" as part of their mandate.

EDIT: I should add this... "crime" is a bit of a loaded term when it comes to problem solving. It implies criminal intent (or at least negligence) which can result all sorts of issues (e.g. "who did the crime?", "we can't accuse MWER!") that get in the way of problem solving. Personally, I feel like I am pushing things when I use the word "blame" in approaching problems, but when I verbalize that word I try to include a disclaimer in place that I'm using it as a short for causal actions/results because of my personal upbringing where "blame" was a routine part of my childhood.

Something that came a little late (for my own taste) was the explicit mentioning that it is possible (and encouraged, in science) to be able to duplicate the problem in a controlled manner. Perhaps this is a little complicated by the people/physics approach? I feel that (in)ability to duplicate the problem would have been a good (explicit) strategy for "eliminating a forked path".

The one early example/model I think I'd be tempted to carry through is the "Swiss cheese". I realize that the Swiss cheese model is inherently supposed to demonstrate the alignment of small factors, but it does offer the chance to explain how variation in one factor (sliding a piece of cheese around) could eliminate a negative outcome, as well as comparing such a strategy with an overall reduction in the size of the holes in the piece(s) of cheese.

 

[Bev D]

great feedback, thanks!

If I were to publish this I would put the embedded examples in a sidebar to keep the explanation clean and fluid. In my training I have found that using small (humorous) examples during the explanation helps keep the students interested and engaged. some like it, some don't.

The police example is actually how the crime investigation is supposed to occur: start with the crime, understand the victim and work back to the perpetrator. (note there is a difference between a police action and an investigation.) Of course, just like problem solving, crime investigations can go horribly wrong when agendas, biases and strongly held beliefs over ride objectivity...

Physical 'duplication' or replication is not usually possible for human behavior based problems. We typically have to rely on logic and the actual evidence to rule out other paths of what could have happened but didn't. This is all that saves us from biased opinions... It is not only possible and all but required for physics problems...replication is the foundation of all science...

I thought about being more explicit in the swiss cheese theory and other things but eventually left it to the reader to apply it in the two examples in part 3 (tomorrow) as it was an introduction and it was getting long. There are many details, specifics and seeming subtleties that I left out. This particular topic takes almost 3 weeks to teach in real life...

 

[Tidge]

Physical 'duplication' or replication is not usually possible for human behavior based problems. We typically have to rely on logic and the actual evidence to rule out other paths of what could have happened but didn't. This is all that saves us from biased opinions... It is not only possible and all but required for physics problems...replication is the foundation of all science...

It is true that replication can be impossible (also for complete/expensive physical systems), but I think it is possible to still do controlled testing... if the duplication is impossible, I think we'd still need a reason to close off a potential contributing branch. Human Factors Engineering isn't black magic, even if some of the sample size recommendations may be peculiar. We "know" what happened at Three Mile Island, and nobody is recommended trying to duplicate that.

For the human element, I believe it is necessary to go beyond "human did something wrong" with simple considerations of "were they distracted?", "did they have a different mental model in play?" (like with the cigarette lighter), etc.

 

[Bev D]

It is true that replication can be impossible (also for complete/expensive physical systems), but I think it is possible to still do controlled testing... if the duplication is impossible, I think we'd still need a reason to close off a potential contributing branch. Human Factors Engineering isn't black magic, even if some of the sample size recommendations may be peculiar. We "know" what happened at Three Mile Island, and nobody is recommended trying to duplicate that.

For the human element, I believe it is necessary to go beyond "human did something wrong" with simple considerations of "were they distracted?", "did they have a different mental model in play?" (like with the cigarette lighter), etc.

I always have logical and evidentiary reasons to close off alternatives paths…always. And i never advocate for anything different.

Can you give two examples? One where replication is possible and where it isn’t but the objective evidence is clear? For the fill exampel I used replication was possible and was performed. In part 3 I give an example where replication is not really possible, but the causal mechanism is so cornered that it is fairly obvious…

 

[Tidge]

I always have logical and evidentiary reasons to close off alternatives paths…always. And i never advocate for anything different.

I wasn't thinking of a defect in the teacher! The explicit reference to contributors to use errors was a suggestion for the students of the material.... no insult intended!

For replication... often when humans are involved I try to leverage "fault insertion" to see if the user recognizes that "something is wrong". So maybe the necessary tool is removed, or replaced with an inappropriate alternate.... and then observe the user(s). There has to be some followup/interview to zero in on why a wrong tool may have been used. (e.g. user expected that they were given the correct tools, user didn't think it would make a difference which tool was used, etc.)

I'm a little tentative about the "root cause is obvious" because from part 1 we are trying to dispel the "myths of 5-why". I think there is a little bit of a slope when it comes to problems and how to solve them, so I would only bring up such a case to demonstrate if/how such a circumstance would play out in a 5Why analysis (if necessary).

 

[Bev D]

I usually find that the cause can become (not always but sometimes) obvious when you have it cornered…in other words you have traversed the backwards path to the extent that not much else is left. Or as Arthur Conan Doyle as Sherlock Holmes said in the Sign of the Four: “my dear Mr Watson, once you eliminated the impossible, whatever remains, no matter how improbable, must be the truth”.

 

[Miner]

@Bev D Excellent part 2.

 

[Bev D]

Thanks!