The previous section showed how the operators at the Little River Plant did a 5 Why investigation which revealed that packaging damage in the store led to damp cardboard feeding into their box forming machine.

They recorded their investigation into the RCA Rt software to communicate the problem to other shifts and to save the information for future reference.

The RCA Rt screen is shown below. Note the remark at the top right of the image which says that Risk has not been set. The company policy is that 5 Why investigations are always followed by a Risk investigation. So the Risk menu button is clicked to reveal the risk matrix.

The wording in the rows and columns in the Risk Matrix may be changed by the System Administrator to reflect the nature of Risk at the site. Every different site will have different Risk profiles and therefore different wording in the rows and columns.

In this case the risk matrix has been configured by the System Administrator at the Little River Plant to show company policy for various relationships between likelihood and consequence which is "Risk".

In this case the operators decide that reoccurrence of the problem is fairly unlikely but is Possible because the cardboard packaging might be damaged in some other way, so they decide to use the "Possible" row. Looking across the consequence columns they decide that the stoppage to production was less than an hour so they look in column 2 the Minor column. They click their mouse on the intersection of the Possible Row and the Minor column on the box which has a value of 25. This causes the following dialog box to appear.

Click Ok to accept and you will see the following note appear in the top right of the Risk Matrix.

The note "Risk: 25 - Single person 5 Why" indicates that the minimum company requirement for this problem was a 5 Why investigation carried out by one person. In this case a few of the operators worked together on the 5 Why investigation so the investigation was done at a higher standard than the minimum and no further investigation is required. In the worst case where perhaps some other factor was working to stop the machine then they will see more downtime and will ultimately investigate further. So the consequences of failure are small compared with the cost of doing a deeper investigation