Learning from Success

As we have discussed, for every event sequence, there is a road not travelled because of some control that worked or some other barrier, whether intended or unintended. That alternative pathway can be uncovered by asking 'what if?'. This approach would disclose an alternate event sequence, together with its own root cause factors. If we now overlay the '5 why's' technique with a new set of questions for every factual scenario to uncover the alternate trajectory of the incident by asking five "what if ?" questions. Through that process, the investigator can uncover any holes not otherwise identified on each Swiss cheese slice and also which controls are in fact working. The latter category is useful to the analysis of "what went right?" as opposed to just "what went wrong?".

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