Root Cause Detective

Something got out the door. Find out why, and don't blame the operator.

Open case files

CASE FILE

Locations

🕒 7:00 AM

Notebook 0

Clues you find will be written down here.

Close the case

1 Sort your clues onto the fishbone

Which category does each clue belong to? Clues that only describe the problem go under "Symptom".

2 Why did it happen? (occurrence root cause)

Cite the clues that prove it:

3 Why didn't we catch it? (escape point)

Cite the clues that prove it:

A

Verdict