Find the Root and Choose a Next Step

What this session can decide

Select causal hypotheses and actions the group can test itself. Do not determine responsibility for accidents or individual responsibility.

Outside its scope

• Do not replace accident or misconduct investigations.
• Do not designate an individual as the root cause.
• Do not assert causal relationships as established.

Primary caution: Do not replace accident or misconduct investigations.

Before starting

Question and scope

Deepen the questions, distinguish observed facts from factors people can influence and connect them to small actions. Before the session starts, state the subject and period to be covered in one sentence.

What is decided here

Select causal hypotheses and actions the group can test itself. Do not determine responsibility for accidents or individual responsibility.

Output recipient

At the end, the Recorder retains “Commitments to small actions”. Create improvement experiments with responsible people, start dates and checking methods.

Participation and information boundaries

Explain that people may pass, rest or leave, and keep personal information, confidential information and judgements about attributes off the recording surface. Assign Participant support separately.

Operating team

Assign the Lead facilitator, Recorder, Timekeeper and Participant support before starting, and confirm who announces transitions and stops.

Next check

Decide the review date for “Commitments to small actions”, who may view it and who is responsible for the next decision.

Who takes responsibility

Lead facilitator

Keep “Find the Root and Choose a Next Step” within its purpose and stated exclusions, and announce the start and end of each stage.

From before the start until the session ends.

Recorder

Record “Chain of questions”, “Observed facts and factors people can influence”, “Commitments to small actions” at each stage and hand the records to their recipients at the end.

From preparation of recording surfaces before the start through storage after the session.

Timekeeper

Notify the Lead facilitator 3 minutes before each stage ends and when switching to breaks or buffer time.

At the start of every stage and 3 minutes before its end.

Participant support

Receive requests to pass, rest, leave or check individually, and decide with the Lead facilitator whether resumption is possible.

From before the start until the session ends.

Session flow

Minutes are measured from the session start. Method time, transition time, breaks and buffer are shown separately; they are not additional overlapping activities.

1. 0–23 minutes

   Re-examine what the problem means

   Method: Nine Whys · 0–20 minutes. Transition: 20–23 minutes (3 minutes).

   Starting with the initial problem statement, ask progressively why it matters. If the same words recur, return to observed facts and state in one sentence what the work brings to whom.

   Responsible: Lead facilitator; Recorder; Participant support

   Output: Chain of questions

   Handoff: Place the final question and observed facts at the centre of the dialogue.

   This stage may be shortened only in accordance with the stated conditions.

2. 23–86 minutes

   Find factors people can influence through observations and exceptions

   Method: Discovery and Action Dialogue · 23–83 minutes. Transition: 83–86 minutes (3 minutes).

   Compare a situation where the problem occurred with one where it did not occur under the same conditions. Separate observed behaviour from interpretation and record differences that can be reproduced in the setting.

   Responsible: Lead facilitator; Recorder; Participant support

   Output: Observed facts and factors people can influence

   Handoff: Return factors people can influence to participants as possible actions.

   This stage is not marked as shortenable.

3. 91–114 minutes

   Select a first action within existing authority

   Method: 15% Solutions · 91–111 minutes. Transition: 111–114 minutes (3 minutes).

   Write actions that can be started without additional authority or budget. Each person selects one and decides who will start when and what to observe.

   Responsible: Lead facilitator; Recorder; Participant support

   Output: Commitments to small actions

   Handoff: Pass the commitments to the responsible people and the organiser of the next check.

   This stage is not marked as shortenable.

What is retained and who receives it

Materials and setup

Material names, quantities, groups and handling instructions retain the fixed draft's original helper-derived guidance. Where a format is marked “Source material specification”, the entire bound English source material entry takes precedence over the old helper-derived format guidance. This format-only correction does not resolve other instruction or safety concerns. English names are not substituted into a Japanese-keyed lookup.

Setup for each method

When to switch or stop

Fallbacks

The same explanation continues through the 5th step.

Return to the preceding question and write one recent, specific situation.

Method guide: Nine Whys

Stop conditions

Individuals’ names or attributes are fixed as the cause.

Stop discussion until the description returns to behaviour, conditions and systems.

Establishing the facts of an accident, legal violation or misconduct becomes necessary.

Preserve the records and refer the matter through the formal investigation channel.

Sources, rights and limits

This site has composed this programme’s purpose, method sequence, delivery instructions, roles, outputs and switching conditions. See each individual method page for that method’s sources and licences.

Original source records and their required notices are retained below. Their presence does not mean a new legal or cultural-safety clearance. Original citation titles are kept in their source language.

Japanese resources and historical source records

Original Japanese plan and its print view · Japanese operation pack or starter materials

An English print edition is not provided here. The linked plans, print views and operation materials are Japanese resources.

Historical recorded publication holds

The following original hold statements are retained verbatim with their fixed source versions. They are not a statement of current acceptance, nor does this historical label resolve a source-specific restriction.

• English translation and rendered-page independent acceptance pending
• Method dependency source/text SHA binding and current source-specific rights verification pending
• Publication not cleared