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You’ve investigated an incident, and now it’s time to write up your report. This report should document what you’ve found, and the corrective actions needed to prevent recurrence or mitigate the problem to an acceptable level.

At the heart of a good report is a strong, clear executive summary.

What does an executive summary look like? Is it a dot point affair? Is it a few one-liners that capture the critical elements of the issue? Or do you tell a story that recreates everything? Is it something in-between?

While it is certainly not the case that “one size fits all” – particularly given that different companies have different needs and policies – there are some golden rules that can be applied in crafting the perfect executive summary.

Be brief.

An executive summary should be brief and to the point. Yet it must still convey critical information, such as:

• The cause and effect paths identified in the investigation
• Lessons about the causal relationships culminating in the incident
• Rationale behind why certain corrective actions have been recommended

It should only take a few minutes to read. For a manager whose time is precious – and hence will likely not read the full report – the executive summary is their insight into the full investigation.

Be factual, but clear.

An executive summary should be factual, yet written for easy reading.

Everyone should be able to understand it, so avoid words that confuse people. Stick to clear, simple language that is easily read and interpreted.

Avoid ambiguity and generic language, which may lead to alternate interpretations of the information. For example, citing “mechanical failure” could refer to any or all mechanical failures. A root cause analysis targets a very specific failure – a seized motor, for instance – which has very specific causes.

An example: “… a temporary loss of cognitive function.”

An ore truck, fully laden with coal, was driving out of a mine. The engine “died” and the ore truck rolled backwards, hit a bank and flipped over. There was considerable damage but no injuries.

An investigation was launched, and a report produced. This report stated that “the driver had a temporary loss of cognitive function.”

This is not clear. What actually happened was that the driver fell asleep. Why didn’t they just say that in the report? Perhaps the report’s writer was trying to protect the driver from undue criticism. Yet, of course the driver didn’t mean to fall asleep.

The purpose of an investigation is not to point the finger, but to prevent a recurrence. So instead of focusing on “who”, a “why” question is needed in this example to elicit more specific, factual responses.

Avoid technical jargon.

Don’t fall into the trap of assuming that everyone will be able to follow your technical or task-specific jargon. Likewise with abbreviations or acronyms. Try to avoid this type of language.

Instead, write the report for a non-technical audience. This will make it easier for a broader readership to interpret and make sense of it, and reduce the number of questions you field once the report is published.

Use “caused by” language.

With reference to the cause and effect chart you created during the investigation, use “caused by” language to join the causes together. So A was caused by B and C; B is caused by D, E and F; and C was caused by G and H (where the letters represent the causes depicted in the chart).

This approach is simplistic, and deliberately so. It summarises the chart in a language that is easy to follow. It is factual and gets to the point. It avoids “storytelling” and the different interpretations that come from such an approach.

In summary

By following the advice above, you will find that an executive summary is quick and easy to read – and doesn’t take long to write, either.

Be aware that every organisation’s needs are different, and yours may have specific rules around what an executive summary should contain. If you have no template to follow, then use the advice above to craft the perfect executive summary for your investigation.

Having watched one of the best Olympic Games ever this summer in London, with some jaw dropping performances being witnessed, it left me thinking about the reasons behind the athlete’s success. What is it that makes an athlete want to win, what gives them the desire to train every day for a chance of winning an Olympic medal?

Whilst listening to British Cycling’s performance director Dave Brailsford, he discussed the success of the British cycling team. “The whole principle came from the idea that if you broke down everything you could think of that goes into riding a bike, and then improved it by 1%, you will get a significant increase when you put them all together”, he said. According to Dave it was these ‘marginal gains’ that underpinned the team’s success.

All of the athletes now need to build on the success of the London Olympics and prepare for Brazil in 2016. How will they recreate the success? How will the athletes break down their achievements into its smaller parts just like the British cycling team?

Do these athletes understand the ‘root causes’ of their success?

Let’s look at the definition of “root cause”:

“Any cause in the cause continuum that is acted upon by a solution such that the problem does not recur” (Dean Gano, A New Way of Thinking, Apollo Root Cause Analysis)

Whilst this definition is valid for solving problems that we don’t want to happen again, we may need to identify root causes of success, just like the Olympic athletes as they prepare for Brazil.

So instead of the term “Problem Definition” traditionally used in the Apollo Root Cause Analysis methodology, we can replace it with the term “Success Definition”.

The Realitychart that results from following the Apollo Root Cause Analysis methodology will no doubt have many conditions such as ‘tenacity’, ‘perseverance’, and ‘dedication’, along with actions such as ‘up at 5am’ and ‘run 10 miles’.

So whilst we do need to solve problems in the workplace and break them down into their smaller parts to achieve the marginal gains for improved plant performance; we also need to understand when our targets have been achieved and performances have exceeded last year’s requirements. Why did we achieve what we set out to achieve? Or, what went well? In this case, it’s not about preventing a problem from recurring but rather repeating a success.

Performing Root Cause Analysis on success is quite possibly a new concept but one that should not be ignored.

To be, or not to be, that is the question:
Whether ’tis Nobler in the mind to suffer
The Slings and Arrows of outrageous Fortune,
Or to take Arms against a Sea of troubles…

“To be or not to be” is the opening phrase of a soliloquy in William Shakespeare’s play “Hamlet”. It is perhaps the most famous of all literary quotations, but there is deep disagreement on the meaning of both the phrase and the speech. Whilst we won’t be solving that disparity in this article, we will discuss the disagreements amongst the global engineering community as to whether the 5 Whys process is sufficient enough to effectively identify the root causes and ultimately, the solutions, for a particular problem.

Why – Why – Why – Why – Why?

The 5 Whys is a question-asking technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem.

The technique was originally developed by Sakichi Toyoda and was used within the Toyota Motor Corporation during the evolution of its manufacturing methodologies. It is a critical component of problem-solving training, delivered as part of the induction into the Toyota Production System. The architect of the Toyota Production System, Taiichi Ohno, described the 5 Whys method as “the basis of Toyota’s scientific approach . . . by repeating why five times, the nature of the problem as well as its solution becomes clear.”

However, whilst the tool may have had success in the automotive industry it has received criticism from within other industries for being too basic and not complex enough to analyze root causes to the depth that is needed to ensure that solutions are identified and the problem is fixed.

There are several reasons for this criticism of the 5 Whys method:

• Tendency for investigators to stop at symptoms rather than going on to lower-level root causes
• Inability to go beyond the investigator’s current knowledge – cannot find causes that they do not already know
• Lack of support to help the investigator ask the right “why” questions
• Results are not repeatable – different people using 5 Whys come up with different causes for the same problem
• Tendency to isolate a single root cause, whereas each question could elicit many different root causes
• Considered a linear method of communication for what is often a non-linear event

Many companies we work with for training and engineering services successfully utilize the 5 Why technique for very basic incidents or failures. By utilizing the correct placement of triggers, organizations can use the 5 Why for its basic problem solving and then move to a form of Cause and Effect analysis like the Apollo RCA method for more complex problems.

A disciplined problem solving approach should push teams to think outside the box, identifying root causes and solutions that will prevent reoccurrence of the problem, instead of just treating the symptoms.

Any effective problem solving technique should meet the following six criteria:

1. Clearly defines the problem
2. Clearly delineates the known causal relationships that combined to cause the problem
3. Clearly establishes causal relationships between the root cause(s) and the defined problem
4. Clearly presents the evidence used to support the existence of identified causes
5. Clearly explains how the solutions will prevent recurrence of the identified problem
6. Clearly documents criteria 1 through 5 in a final RCA report so others can easily follow the logic of the analysis

RealityCharting has come up with a simple, free tool that can be used to help with a 5 Why investigation. RC Simplified™, the free to download version can be utilized on smaller issues as it allows the user to build a cause and effect chart that is no greater than 4 causes high and 5 causes deep. This means the user of a 5 Whys approach can create a Realitychart using the same thought process adopted in the Apollo Root Cause Analysis methodology. It also demonstrates a non-linear output to what was originally considered a linear type problem.

So when looking for problem solving tools or root cause methodologies, be willing to “think outside the box” and utilize a number of resources depending on the complexity of the problem and the significance of the incident. We believe that the 5 Why’s approach definitely has a time and place to be utilized. However, if the problem is more complex, don’t limit yourself to a 5 Why approach as you will likely not be satisfied with the solutions generated.