Problem Solving: Test the Explanation Before the Fix

Human Performance weekly series: lesson 36 of 52.

A 5–10 minute crew discussion, plus time to verify the actual controls. The crew talk and Word version are public. Separate supervisor and attendance records are included with free Safety & Systems membership.

Why this matters

When a problem repeats, the first explanation can become the accepted cause before anyone checks it. Separate what was observed from why people think it happened. Keep current exposure controlled while the team gathers evidence; uncertainty is not permission to experiment on operating equipment.

Learning objective

Describe one work problem without assuming its cause, then identify a safe evidence check and a observable improvement.

Key hazards or failure points

A favored explanation; missing work context; fixing symptoms; unsupported cause claims; unauthorized troubleshooting; a change introducing another hazard; closure based only on completed paperwork.

Practical controls

• Write the observed difference between expected and actual conditions. Include location, timing and the people affected. Ask those doing the work what they encountered; preserve information that does not fit the first explanation.
• List plausible explanations separately from observations. Involve the required technical people and choose an authorized way to examine the evidence. Maintain interim protection; do not disable safeguards or recreate a hazardous failure.
• Before implementing a proposed fix, obtain its required review and authorization. Identify the expected result, responsible owner and follow-up method. Retain safeguards until the approved replacement controls are ready.

Verify It in the Field

• Use a deidentified paper example. Ask the crew to underline observations and circle assumptions in the problem statement. Rewrite a label such as careless work as the actual condition observed; record what remains unknown.
• Choose one explanation and identify evidence that could support or contradict it. Locate the governing procedure and authorized verifier for any field check. If no safe approved method is available, record the gap and refer it rather than testing.
• Trace one approved action to a real control check. Record the acceptance source, method, actual finding, checker and time, then compare the result with the stated objective. Schedule a later check where continued performance matters.

Stop and reassess

Hold affected work when protection is uncertain, evidence conflicts or a proposed check exceeds authority. Use the task’s safe-state process and escalate. Do not declare a cause proved by agreement or one successful attempt. Correct the plan and verify required conditions before authorized restart.

Crew discussion questions

• What did we actually observe?
• What evidence could challenge our explanation?
• How will we know the change helped?

For each required control, record its acceptance source and criterion, safe verification method, responsible checker, actual result and time. Use VERIFIED, HOLD/NOT VERIFIED, or N/A with a reason. A tick alone is not evidence. Complete all applicable task inspections; do not enter danger or improvise a test to fill out a form.

Leader preparation and practical detail

The symptom is not the cause

Illustrative situation: a barrier is repeatedly displaced. Instead of concluding that workers ignore it, examine delivery routes, attachment suitability and who maintains it. Keep the area protected while investigating. Evidence may support several interacting conditions; do not force a single cause simply to complete a form.

Testing means checking evidence safely

This lesson permits a paper exercise, not operational troubleshooting. Actual measurements, trials or equipment changes need the governing procedure, competence and authorization. Records or an already safe observation may answer the question without recreating the event. Technical acceptance criteria come from the actual system, not this discussion.

Check benefit and side effects

An approved change can solve one difficulty and create another. Ask affected workers whether access, visibility or workload changed, and inspect the resulting protection by the authorized method. OSHA guidance supports interim protection and verification of control effectiveness. It does not prescribe PACTS or guarantee a particular reduction in error.

Short supervisor field check

• Observed problem separated from assumptions.
• Worker and technical perspectives included.
• Safe evidence method and verifier identified.
• Interim protection and change authority confirmed.
• Effectiveness result and follow-up recorded.

Confirm the relevant trained/authorized people, unresolved items, interim protection, correction owner and recheck. Record required release authority and rebrief anyone affected. The separate sheet supports these records; it does not replace a specialist inspection, permit or engineering determination.

Attendance and follow-through

Use the separate attendance sheet for participants, roles, discussion concerns, actions and late-arrival rebriefs. Attendance is not proof of competence, functioning controls or authorization to work. Keep completed records private under employer procedures.

Source acknowledgment

This resource draws on the U.S. Department of Energy’s DOE-HDBK-1028-2009, Human Performance Improvement Handbook, Volume 2 (June 2009). Todd Jerome Jenkins makes no claim of authorship or copyright ownership in the original U.S. Government work. New explanations, examples, exercises and layouts are Todd Jerome Jenkins adaptations. No endorsement by DOE or the U.S. Government is implied. Third-party material credited in the handbook remains attributed to its source; this notice does not claim rights in that material.

Source excerpt: Volume 2/VOLUME 2 PROBLEM SOLVING – WITH PACTS.pdf; Printed pp. 61, 62. The June 2009 handbook supplies concepts; this lesson uses original explanations and exercises.

Technical scope and references

References reviewed October 9, 2026. DOE human-performance tools and OSHA recommended practices support preparation and discussion; they do not establish universal technical acceptance criteria. Apply the current task procedure, manufacturer instructions, permit and required competent or qualified decisions. A successful exercise does not replace required training, technical verification or work authorization.

1. DOE-HDBK-1028-2009, Volume 2 — Structured problem solving — June 2009 illustrative guidance; printed pages 61, 62. Historical concepts, not universal mandates.
2. OSHA Recommended Practices — Hazard Prevention and Control — Current recommended practices; supports assigned responsibilities, worker input and evidence-based follow-through. Not a technical acceptance standard.

Connect this discussion to your JHA/JSA

Use the JHA/JSA planning and field-verification worksheet to record the actual task steps, hazards, responsible roles and controls. No task-specific worked example is linked for this topic yet. Return to What Changed Today? when the plan or conditions change.

Related Todd Jerome Jenkins articles: How to Conduct a Job Safety Analysis and What Is Human and Organizational Performance?.

Related crew discussions

• Incident Learning: Reconstruct the Conditions and Decisions
• Choose the Gap to Fix First

Continue the weekly series

• Lesson 35: Decisions Under Uncertainty: Make the Trade-Offs Visible
• Lesson 37: Peer Review: Check the Technical Basis Before Release

Put one check into practice

Use the free JHA/JSA planning and field-verification worksheet to record today’s change, the required protection and the evidence needed before exposure.