Use Five Whys With Evidence, Not Guesses
Run a Five Whys analysis that moves from symptom to process cause without blaming the last actor.
Breaker 22 has tripped three times in 10 days during morning ramp. The team needs to move from symptom to preventable process cause. Evidence-based Five Whys: symptom -> causal layer -> process condition -> corrective action The common trap is stopping at the last human action or failed component instead of asking what process allowed that condition to persist. Why 1 Why did Breaker 22 trip? Event record shows undervoltage protection operated during morning ramp. Start with instrumented fact, not the loudest theory. Why 2 Why did undervoltage protection operate? The downstream load ramp created a voltage dip below the…
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