#5 whys
The '5 Whys' root cause knife. Unpacking Japan's simple trick adopted by shift personnel to dissect genesis faults. Analyzing real cases where mere 'inattention' unraveled deeply-rooted gear failures.
Regular Incident Analysis: From Blaming Individuals to Systemic Solutions
Incident Investigation: Not About Blame, But Hunting for Root Causes
Exercise for Practicing the Identification of Accident Causes: Immediate, Underlying, and Root
Hazard Observation Cards Methodology as a Near Miss Management Tool
Implementation of a system for collecting and analyzing hazard observation cards (HOC) for near miss management. The practice includes a four-step HOC algorithm, accounting automation based on an internal IT solution, application of the "Five Whys" and "Bowtie" methods for investigation, and financial motivation of personnel for active risk identification.
Why Use a Structured Approach in Accident Investigation?
The "5 Whys" Method: A Simple Tool for Finding the Root Causes of Incidents
The Deep Roots of Workplace Tragedies: Digging to the Very Core!
Internal Incident Investigations in Industrial Safety: Not a Punishment, but a Development Tool
"Learning from Mistakes" or How to Conduct a High-Quality Incident Investigation
Implementation of the A3 incident investigation methodology to shift from blame-seeking to systemic root cause analysis. The practice includes a step-by-step fact-gathering algorithm, application of analysis tools (timeline, cause tree, Ishikawa diagram, barrier diagram), and evaluation of corrective actions using an effectiveness-cost matrix.
HSE Integration into Production System Practices. NLMK Experience
Integration of HSE and operational efficiency processes through cross-functional teams and the Idea Bank system. Implementation of lean production tools (5S, A3, mapping, Five Whys) into daily HSE practices, including shift meetings and standard operating procedures.
HSE Incident Investigation: Goals, Objectives, Methods
Implementing a systemic approach to investigating all incidents, including micro-injuries, focusing on finding root causes instead of assigning blame. The practice involves the sequential application of analytical tools (5W1H, 4M analysis, "5 Whys") by cross-functional working groups and mandatory horizontal scaling of corrective measures to adjacent departments.