When should I use the “5-Whys” causal analysis?


Causal Analysis has many tools for getting to the “root” cause of a problem. This subject has many ways to attack it with the “5-Whys” being a generically accepted rudimentary process of quickly rooting out the originating driver(s) for an issue. There can be issues with multiple degrees of significance or “levels” of how deep an investigation must go to find personal and organizational issues, sometimes referred to as Basic Low Level (BLLs), Apparent Cause Evaluations (ACEs), or even higher order, “Root Causes.” Note the capital “R.” A Root Cause is extremely significant, formal, and should require a lot of teamwork: multiple investigators, multiple reviewers, and multiple techniques to discover what happened, causal factors, and then to develop what some people call “Corrective Actions to Prevent Recurrence” (CAPRs – pronounced as “capers“). In my view (some in the field are not always aligned on this) CAPRs should be created to prevent this same type event, or other potential similar events from occurring in the future…. These are the highest order of corrective actions. In a similar, but a little different way, corrective actions for ACEs should prevent the same type of event from happening again, and lowest level investigations are designed for ensuring that problem is fixed in a timely fashion and that it is coded properly for trending. Root Causes and Apparent Causes have corrective actions that are typically reviewed and agreed upon by a committee based on their organizational cost and resource impact.

Note that different Corrective Action programs call the different levels of investigation different terms, but most widely accepted are the most serious “Root Cause” and the next level “Apparent Cause.” Levels are given, so you do not put all of your resources (time, money, and personnel) equally on every event.


The 5 why’s (also seen as “5Ys”) typically refers to the practice of asking, five times, why the failure has occurred in order to get to the root cause of the problem. This process is not to be mistaken as a formalized way of discovering difficult issues surrounding an event investigation.

To give this concept more context, let’s liken this process to a simplified training needs analysis (TNA). The training question could be: Does James need training to do process#1? Well, if I hold a gun to his head, can he perform the function (Is it just a case of stubborn will)? If he can perform the basic function, maybe he just needs a procedure, or some practice, but not a training class… and so on… simple, basic, and high-level… that’s what the 5-Why’s is – simple, basic, and high level – it could truly reveal something you were not aware of before, but note that it is the least powerful causal analysis technique in the Root Cause Toolbox: Event and Causal Factor Charting, Barrier Analysis, Fishbone, Timeline, Change Analysis, Substitution Analysis… and the list goes on and gets more in depth. I relate the TNA “gun to head” philosophy in the same way I do the 5Ys – it is a short and simple way to get you in the ballpark for discovering unknowns.

Of course, there can be more than one cause to a problem as well. In an organizational context, most Root Cause analysis is carried out by a team of persons related to the problem with a qualified investigator.

Where are the links?

I did not include links to websites or scholarly articles on this subject – I prefer not to think of it as a professional causal methodology for experts to use, but one that is accessible to anyone looking at an investigation. Check out the videos and see how it is used, and for a good laugh related to this material, click the picture above.


Toyota’s “Go and See” process with fishbone diagram

The 5 Whys

Gemba Glossary: The 5 Why

5 Whys

The 5 Whys Problem-solving Method


Do you know of a tool that can determine if a leadership team and an organization are aligned?

alignmentI’m going to share with you two major commercial nuclear power industry leadership problems formerly identified on an INPO Training development team I was on in 2013. It may come as no shock, but the two things we needed to get better at were coaching (being intrusive in a job observation), and leadership alignment (everyone on the same page with the same goals and vision). For this post I’d like to address leadership alignment, what it is and what can be done about it. I won’t pretend to have all of the answers here, but per the usual, I will have recommendations based on research that I share with you. You cannot strive to improve something if you do not really know what it is you are trying to improve. Defining the problem/issue accurately is sometimes more than half of the solution.

Dozens and dozens of pretty specific definitions of what is true leadership exist, but for the purposes of our alignment discussion let’s use Berkeley College’s, “The Leadership Quarterly” to explain it:

It seems that leadership is how well you implement the following objectives with your workforce (note that it’s a lot about communicating and handling change):

  1. Clearly articulates the strategy
  2. Provides a compelling vision
  3. Provides measurable objectives for implementing the vision
  4. Recognizes and rewards progress in implementing change
  5. Responds effectively to resistance to change
  6. Personally inspiring and motivating for the change
So, how do you define alignment?

“Linking of organizational goals with the employees’ personal goals, requires common understanding of purposes and goals of the organization, and consistency between every objective and plan right down to the incentive offers.” [Source]

Hmmm… this doesn’t feel like the right definition to me – we are seeking what Leadership alignment is, not a misaligned org/worker goal thing. How about this:

“Organizational alignment refers to the existence (or absence) of a consistently clear understanding of the organization’s purpose throughout the business organization’s entire value chain.” [Source]

Nope, this still doesn’t feel like it hits the mark…

I’m left wondering if the term “Leadership Alignment” is really a creation of fiction.

Does alignment matter more than good individual leadership?

“In organizations of any size it is likely that organizational performance should be related to the aggregate effects of leaders at different hierarchical levels.”

“…it is clear that leaders at different levels influence strategic initiatives and their implementation, how aggregate leadership influences organizational performance is not straightforward. For instance, a powerful senior leader may compensate for less effective leaders at lower levels. Alternatively, a less effective but highly aligned set of leaders across levels may successfully implement change.”

[same source as above]

With this in mind, I am left to surmise that successfully implemented changes is a trait of a good organization, properly influenced by leadership. I also do not know the official answer to this question – I think the answer can be yes or no, depending on the mission and flexibility of the team.

Paired Observations

Another way of assuring or creating leadership alignment is by having leadership do observations of other leadership performing observations. Does that sound crazy? Well, it’s actually a pretty powerful tool when done correctly. Part of doing it correctly involves the “paired” observer following the leader around through a work observation evolution and then debriefing the things that went well and any gaps to performance in private. A lot may get learned in these sessions, because the paired observe may learn of things they weren’t aware of, or maybe even afraid to ask a subordinate.

Zero Zeta Tool from Behavioral Science Technology, Inc. (BST)

Note that this tool will help to discover where misalignments exist in an entire organization, not just within leadership. I went through BST’s training on this tool in Dallas Texas in 2010.  The tool is amazing and extremely underused for it’s various possibility and alignment function.

Consider six levels of maturity in an organization on a taxonomy – starting with farthest from valuing, and moving to internalization. (Author’s note: If you have been paying attention to my other posts, the AFFECTIVE DOMAIN is in play here. If you forgot, the Affective Domain is Receiving, Responding, Valuing (*internalization level), Organization (*advocacy level), and Characterization (*fanatical level))

[*my paraphrases]

As department personnel use this classification process and voting for each, you can determine if alignment exists.

The ten dimension scales for BST’s Zero Zeta tool:

  1. Vision
  2. Leadership
  3. Structure
  4. Culture
  5. Engagement
  6. Expertise
  7. Exposure
  8. Enabling Systems
  9. Sustaining Systems
  10. Scorecard

For the BST supporting webcast video click here

How do you fix alignment?

The Leadership Alignment Work Mat

My thoughts – this model is pretty great at helping you see relationships between different significant “domains” or “realms” within a multi-employee business, but by itself I don’t see this having the full effect for fixing leadership alignment issues… so, if we mix this idea with the Zero-Zeta concept, define the Domains that our organization is built on, then further define the taxonomies within those domains, we can then have the model for our site.

Each domain comes with a simple value question – where do you feel we are within the taxonomy? Give these 10 minute survey questions out for each custom domain, see where leaders (or even workers) say they feel the organization is, and then you will know your misalignments and what to work on.

In action:

As an example of a taxonomy: If you have a Domain for Organizational Error Culpability it could (but shouldn’t – this is off the top of my head simply for explanation purposes) look like this:

  • Organization: The Organization allows workers to be set up for failure
  • Managers: The Managers allow workers to be set up for failure
  • Supervisors: The Supervisors allow workers to be set up for failure
  • Workers: Workers create situations where they fail
  • No Issue: Workers do not fail because of process

Once you have all of your domain areas (multiple taxonomies), you ask individuals to grade them on where they believe the organization is within each taxonomy.

Once you have that data compiled, you can compare answers to see if everyone feels the same problems and triumphs exist in the organization.

If everyone is aligned, you all are agreeing on similar gaps, and you have work to do closing them…. if everyone is not aligned, then you have an alignment gap AND whatever other problems your organization is dealing with.

In a nutshell that’s what I would do to determine gaps and if an alignment issue exists, as well. Survey Monkey is your friend.

Author’s note

This is one of my favorite and I believe one of my most valuable posts. Because of this, I’ve waited a while to make it available and to let readers have a full appreciation for all of the parts that feed into the idea of multiple custom taxonomies used for measuring leadership and organizational alignment. To truly get the value out of it takes contemplation and possibly collaboration. Feel free to contact me for questions.



What do you know about Decision Making? Here are 6 tools to help!

give_red_blue_pill_choice_800_clr_15013How often have you heard or thought about your decision making process? The outcome of our decisions pretty much choose our entire life outcome. Have you noticed that certain types of people are really good at making decisions? These are the kinds of people we try to be and we want as spouses, friends, colleagues, and also the kind of people we try our very best to teach our children to be. We are very human, however, and always making the best decision sometimes eludes us, but we can build a toolbox of suggestions for consideration when making a new decision. Here are some tools I’ve created or found along the way to help with the decision-making process. I hope you decide to use them:

Tool #1: Research

When buying a product or service we have buyer’s guides (that cost money), Consumer Reports, Angie’s List or even free resources like CNET and a host of other places to look into online to determine the reliability of the item and the worthiness of the cost. Some people are very good at research, but still very apprehensive to buy. Even movies get critic ratings that some of use review to see if it’s a movie or show we’d like to spend our time watching or not. Decision making research can be helpful, but is not always available, depending on the context of the situation. When considering a decision, there are thousands of places to research online covering a myriad of topics.

Here are some helpful FREE online research resources:

Google Scholar (Did you know this existed?)

International Institute of Social Studies

Enoch Pratt Free Library

Wiley Online Library


Open Library


Tool #2: Second and Third Opinions

Have you every ran something by your parents? …or spouse? …or best friend? This idea is very standard and basically is just running the parameters of the decision by someone you trust, and getting their input before your final move. Caution on this one: make sure they are good listeners before trying this, and you respect their previous decisions on similar matters.

Tool #3: Gut Check

Do I feel right about the decision? Are there moral or ethical ties to this decision that are keeping me from making it or not? If so, maybe you’ve already made the best decision for you. Doing nothing is a decision.

Tool #4: Similarity Check

Does this current situation resemble a lesson you learned from someone else or yourself from the past? Really think about the parameters and determine if you think it’s similar enough and this becomes your mental model for this new choice.  Another name for this is “Experience.” Here is the famous overarching quote on the matter by George Santayana, “Those who cannot remember the past are condemned to repeat it.”

Tool #5: The (always-biased) Pro vs. Con List

Everyone has used this at one point or another – developing a list of pros and cons that will happen if we decide on way versus another. This list will always be biased, even if you have someone else make it for you, because then their biases will be included. I heard on a podcast that if you look at good decisions you’ve made in the past and ferret out a process for how you came to that decision (Simon Sinek calls them filters), you may be able to apply that process to the current situation. I like that idea better than a biased pro vs. con list, even though it takes work to develop, but you might learn something worthwhile about yourself in the process.

A link to follow up more on this tool:

How to make good decisions? Hint: A pros/cons list won’t help

Tool #6: READE (pronounced as “ready“)

In some parts of the commercial nuclear power world training has been created to help make better decisions under production pressure, operational risk, and other error precursors. Without diving too deep into the training, here is what the overall premise of READE looks like:

Recognize the degraded condition or uncertain situation that threatens safety

Express the situation in terms of consequence (if left alone) related to:

  1. Personal safety and well-being
  2. Plant safety and reliability
  3. Environmental safety

Appraise the situation to identify conditions that could threaten safety

Decide what to do to resolve the situation safely

Evaluate the effectiveness of the actions in achieving the desired results

When should READE be used?

A conservative approach is necessary when encountering the following conditions, or others similar, during activities or processes that could affect safety:

  • Unexpected results
  • Uncertain, degraded, or unstable conditions
  • No slack—low margin for error
  • No opportunities to redo or recover—irreversible actions
  • Complexity—hard to understand
  • Limited guidance—unclear guidance in procedures
  • Need for high levels of precision
  • Multiple concurrent activities that require a significant degree of coordination
  • First time or infrequently performed evolution

Other situations that call for a conservative decision making approach occur in the following situations:

  • A serious performance gap to excellence exists.
  • A significant change to an important plant process or program is being considered that could impact personnel performance.
  • Fast-track job or work assignments are made (to be immediately implemented).

The READE Tool reminds us to include risk and consider consequence when making impactful decisions.

Some extra links you may consider:

[Author note: There are a ton of resources on decision-making… these are just some I think you’ll enjoy across multi-media formats.]


This Freakonomics link will actually HELP you make a decision, no matter how complicated


How to Make Better Choices in Life and Work: Chip Heath

Simon Sinek on How to Make Better Choices and Live More Fully

Confidence-driven decision-making: Peter Atwater at TEDxWilmington


“Decisive” by Chip and Dan Heath


“Decisive”: Chip Heath on How to Make Better Choices


A 4-Step Process for Making Better Decisions by Michael Hyatt


Should I care about “Performance Modes?”

three_volume_set_16417What are “Performance Modes?” We call them Skill, Rule and Knowledge Based performance. These apply to the mode of operation we are in every moment of the day, depending on the situations we find ourselves in.

  • Skill-based – stored patterns of pre-programmed instructions
  • Rule-based – familiar problems are addressed by application of stored rules
  • Knowledge-based – novel situations in which actions must be planned, using conscious analytic processes and stored knowledge

James Reason classified errors based on Rasmussen’s 3 levels of performance:

  • Skill-based errors – slips and lapses – when the action made is not what was intended
  • Rule-based mistakes – actions that match intentions but do not achieve their intended outcome due to incorrect application of a rule or inadequacy of the plan.
  • Knowledge-based mistakes – actions which are intended but do not achieve the intended outcome due to knowledge deficits.

[Source: “Human Performance” from Duke’s Patient Safety]

Error precursor effect on Performance Modes:

Some error precursors are particularly powerful, depending on the performance mode of the individual performing the action. For instance;

Skill-based performance– strongly influenced by distractions, simultaneous tasks, and fatigue

Rule-based performance – strongly influenced by mindset confusing displays, and confusing procedures

Knowledge-based performance – strongly influenced by assumptions, first-time performance of the task, time pressure, lack of knowledge, and inexperience

[Source: “Human Error,” by Brian Harkins, slide 25]

So what?

My thoughts: when someone is performing a procedure they can be in at least three modes at the same time… the mode for the environmental situation (Have I been here before?), the mode for the task they are performing (Have I done this before?) and their general familiarity for performing procedures (Is this my first time?). This is where I believe a lot of investigations that cite performance modes as a cause or contributor to a failure really aren’t helping. I think the best use of knowing which performance mode the worker was in when an error happened is for creating a corrective action better aligned with the actual problem – i.e. a rule-based error should get a rule-based fix. We often start out in skill-based mode and the error happens when something changes and we did not recognize it and fail because of having the wrong mental model (knowledge based mode – you don’t know what you don’t know – fast switch from skill to knowledge). Addressing why the mode changed is an excellent way to develop a solution to prevent that shift in the future.

My bottom line on this is regarding teaching human performance fundamentals to workers. I have not seen worker “aha moments” that will prevent future failure, because we’ve taught them about performance modes in training. I think they should be used as an investigative tool for practitioners and not entirely necessary for workers to bother learning in any detail.

Terms: Skill, Rule and Knowledge

One fo my favorite Nuclear Power plant CEOs and I got into an awesome discussion/debate over lunch about why he thought workers should be in Knowledge Based mode and we should have them trained and supported to have the correct mental model when performing work. The names given to these modes have often confused people because they do not adequately represent the modes they describe….

I think the terms should be more like: Familiar, Instructional, and Unknowns (or Unfamiliar)… that may put a better light on what they actually represent!!!

What are your thoughts? I’m open to criticism and your candor on this post.

Extra Links to support the post:

Click here and check out the SRK Framework section

Understanding Human Behaviour and Error by David Embrey

Patient Safety and Quality Improvement (through Duke University)

Wikipedia on “Human Reliability” (plenty of extra links here)

Author’s note: Sorry for no video link on this post’s top left pic – there are no videos that I could find on the internet associated with performance modes. More content coming soon! Topic suggestions are always encouraged and accepted with open arms!

What exactly is a “Human Performance” tool?

boxy_robot_hold_wrench_14592Oh no – Could a Human Performance Tool maybe not be a tool at all??? In social media space there have been some questions about the actual definition of a human performance tool, so I thought it would be wise to dedicate a post to the namesake website. By the way, our industry is shifting towards being called “Event-Free Performance,” not “Human Performance.” Quite possibly, you did not hear that here first… Feel free to chime in with your thoughts on this historic change.

Let’s start defining a “tool”… and yes, I slightly edited some vulgarity out of the definitions…

google logo


  1. a device or implement, especially one held in the hand, used to carry out a particular function.
  2. a distinct design in the tooling of a book.
  1. impress a design on (leather, especially a leather book cover).
  2. equip or be equipped with tools for industrial production.
  3. drive or ride in a casual or leisurely manner.

Merriam Webster says

Definition of TOOL


a :  a handheld device that aids in accomplishing a task

b (1) :  the cutting or shaping part in a machine or machine tool (2) :  a machine for shaping metal :  machine tool


a:  something (as an instrument or apparatus) used in performing an operation or necessary in the practice of a vocation or profession <a scholar’s books are his tools>

b :  an element of a computer program (as a graphics application) that activates and controls a particular function <a drawing tool>

c :  a means to an end <a book’s cover can be a marketing tool>


My favorite part from the extremely useful DOE Handbook

“For the human performance tools to provide value in improving safety, workers first must possess a solid foundation in the technical fundamentals of the equipment, systems, and operational processes they work with. Facility equipment, work processes, the organization and its culture, and its oversight processes all contain hidden flaws or latent conditions that could cause harm if work is undertaken without thinking. Safety is not obtained by mindlessly applying human performance tools but rather by people conscientiously applying their knowledge, skills, experience and insights, as well as the tools to accomplish their work goals.”

What is your opinion?

I’m sure you already knew this, but if you’re new to the field let this sink in: if using a Human Performance tool saves the day, the system needs to be fixed. I see a Human Performance tool as a simplified method for remembering how to do a best practice when it matters the most – usually and most likely prior to a critical step. These tools are directly about prevention of errors that may quickly translate into an event, depending on the circumstances. Human Performance tools can also be physical barriers of defense to prevent us from doing something unintended, such as railings, shields, or guards near running equipment or ledges. By the above definitions, if a scholar’s book is a tool, than a procedure, job aid, manual, or method is also a tool. That’s how I see it.

Engineering barriers to prevent events

Forget Human Performance tools for a minute, hands down the absolute best way to prevent events is to build in interlocks that serve as hard barriers that do not ALLOW you to make a mistake, like when a computer asks you if you’re sure you want to delete a file. This article was written by an injury lawyer, but it contains exactly the type of thinking professionals in our field need to have – what are the top tools to help workers succeed in the fields we are supporting? Included in this article link are tools for the medical profession that hospital workers should be using:
Click HERE to explore the article.

A suggestion to look into

If you’re working with people that do a lot of monitoring, like security or operators, look into a tool called “Cross-Check”. I have more info on this. Feel free to contact me.

A quick hello…

To all my new Performance Improvement colleagues from the recent NERC and NATF Human Performance Conferences – It was a pleasure meeting you and please stay in touch. Thank you for coming to the website and checking it out.

More links supporting this post: