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๐—ง๐—”๐—ž๐—˜ ๐—ฃ๐—ฅ๐—ข๐—•๐—Ÿ๐—˜๐—  ๐—ฆ๐—ข๐—Ÿ๐—ฉ๐—œ๐—ก๐—š ๐—ง๐—ข ๐—ง๐—›๐—˜ ๐—ก๐—˜๐—ซ๐—ง ๐—Ÿ๐—˜๐—ฉ๐—˜๐—Ÿ๐—ฆ: ๐Ÿฏ ๐˜… ๐Ÿฑ ๐—ช๐—›๐—ฌ๐—ฆ


Most problems are contained and not solved. The same or similar problem will occur somewhere else, to someone else. Solving a problem to root in order for it to never happen again is great. But again, is solving the specific problem always sufficient? Does this take us to operational excellence, and becoming a highly reliable organization?


True operational excellence and high reliability require a more comprehensive approach, considering all three levels of problems:


๐Ÿญ - ๐—ฆ๐—ฝ๐—ฒ๐—ฐ๐—ถ๐—ณ๐—ถ๐—ฐ ๐—ฃ๐—ฟ๐—ผ๐—ฏ๐—น๐—ฒ๐—บ: ๐—ช๐—ต๐˜† ๐—ฑ๐—ถ๐—ฑ ๐˜„๐—ฒ ๐—ต๐—ฎ๐˜ƒ๐—ฒ ๐˜๐—ต๐—ฒ ๐—ฝ๐—ฟ๐—ผ๐—ฏ๐—น๐—ฒ๐—บ?


This involves identifying the root cause(s) of the specific problem and implementing an irreversible countermeasure to prevent the problem from recurring. However, this approach focuses narrowly on one situation. We may miss the broader opportunity presented by the specific problem. Let's go deeper with our thinking.


๐Ÿฎ - ๐——๐—ฒ๐˜๐—ฒ๐—ฐ๐˜๐—ถ๐—ผ๐—ป ๐—ฃ๐—ฟ๐—ผ๐—ฏ๐—น๐—ฒ๐—บ: ๐—ช๐—ต๐˜† ๐˜„๐—ฎ๐˜€๐—ปโ€™๐˜ ๐˜๐—ต๐—ฒ ๐—ฝ๐—ฟ๐—ผ๐—ฏ๐—น๐—ฒ๐—บ ๐—ฑ๐—ฒ๐˜๐—ฒ๐—ฐ๐˜๐—ฒ๐—ฑ ๐—ฒ๐—ฎ๐—ฟ๐—น๐—ถ๐—ฒ๐—ฟ?


Investigating why the problem was not detected earlier helps identify weaknesses in the detection systems. Enhancing these systems can lead to earlier identification of issues, potentially minimizing their impact and preventing dramatic escalation. Problems will always occur; therefore, we need to become more proficient at detecting them.


๐Ÿฏ - ๐—ฆ๐˜†๐˜€๐˜๐—ฒ๐—บ๐—ถ๐—ฐ ๐—ฃ๐—ฟ๐—ผ๐—ฏ๐—น๐—ฒ๐—บ: ๐—ช๐—ต๐˜† ๐—ฑ๐—ถ๐—ฑ ๐˜๐—ต๐—ฒ ๐—ผ๐—ฝ๐—ฒ๐—ฟ๐—ฎ๐˜๐—ถ๐—ป๐—ด ๐˜€๐˜†๐˜€๐˜๐—ฒ๐—บ ๐—ฎ๐—น๐—น๐—ผ๐˜„ ๐—ถ๐˜ ๐˜๐—ผ ๐—ผ๐—ฐ๐—ฐ๐˜‚๐—ฟ?


This is the most critical and often the most challenging level. It requires examining the broader organizational systems (i.e., work system design, maintenance system, etc.), processes, and culture that created the opportunity for the problem to occur. A process is always part of a system and a system part of a bigger system. We need to understand those interdependencies.


By addressing problems at all three levels, organizations can move beyond merely containing or solving specific issues. This approach ensures that problems are not only resolved but also prevented from recurring. By applying the "5 Whys" method to each level of the problemโ€”specific, detection, and systemicโ€”organizations can delve deeper into the root causes, generating broader reflections and insights. Each problem-solving effort thus drives systemic changes that enhance operational excellence across the organization.

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