Descend To The Lowest Level You Can!

How often have you overheard a conversation and heard the phrase, "I don't think they can get much lower than that." Usually, this is about someone in particular and their perceived behaviors. The statement generally has a negative connotation.

How about the sometimes wildly entertaining Caribbean dance, the Limbo? The object is for participants to dance under a bar or pole, that is lowered through successive turns of the participants. When a participant falls, they are eliminated from the dance, until the dancer who can go the lowest remains. The thought is, how low can you go?

When doing an investigation, you want to get to the lowest level you can. You want to peel away the layers of circumstances that will get you to the root cause. This is often done using "Cause of the Cause" or "5 Why Analysis". Fault Tree Analysis is a disciplined approach to these processes. Essentially, you want to go as low as you can go. You want to descend the lowest level possible.

Each hypothetical cause has one or more hypothetical causes subordinate to it. Eventually, you will get to a point where you have exhausted all reasonable possibilities. Typically, you will find that there are usually no more than five levels of "Why" or hypothetical causes. Evaluation of these hypothetical causes then lends you some measure of confidence as to whether they were truly contributory to the Loss Event. The key, however, is to go to the bottom, get to the root of the Fault Tree, or the Root Cause.

When pursuing your investigation, it is important to remember...

Descend to the lowest level you can!