If we were to add the "what went right?" dimension to the root cause analysis technique, we would need to adopt a multidimensional diagrammatical representation. Improving resilience and investigating success of corrective action controls If we are to appreciate the importance of the alternate trajectory of an incident, we need to adapt our approach to traditional incident investigation methods. In incident investigation, we say an incident event occurred because of a series of primary events leading up to it, each causally related to the incident event. These are the direct causes of the event. By asking why these events happened, we uncover the root causes of the event. Take, for example, the popular incident investigation technique adapted from the quality assurance techniques of Sakichi Toyoda for the Toyota Motor Company- the "5 Whys". The technique consists of asking "why?" five times to get to the root cause of an event. An example of doing so is provided below.
• Why did the incident happen? Because the worker didn’t follow procedure.
WHY? 1
• Why did the worker not follow procedure? Because she was not trained in the procedures.
WHY? 2
• Why was she not trained in the procedures? Because training needs of workers were not systematically identified.
WHY? 3
• Why were training needs of workers not systematically identified? Because there is no system for training needs analysis to be undertaken.
WHY? 4
• Why was there no system for training needs analysis to be undertaken? Because training is inadequately addressed in the safety management system.
WHY? 5
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