Scenario 2 Five Whys
Identify the direct causes and actions leading up to the incident – keep asking 'Why?'. Remember that there isn’t ALWAYS 5 Whys. Sometimes there are 3, there could be 5,6 or 7, but you just have to keep going until you can’t ask 'WHY?' any more.
WHY was the wrong packaging used?
The packaging machine had not been cleared of ‘nut-free’ chocolate wrappers on the previous run.
WHY had the machine not been cleared?
The operator had not been trained.
WHY was the operator not trained?
There was no requirement for the operator to be trained.
WHY was training not required?
An allergen risk assessment had not been conducted so a training requirement had not been identified.
WHY was an allergen risk assessment not conducted?
Safety risks from allergens were only evaluated on an informal basis and the requirement for a formal assessment is not included in the standard operating procedures for the business.