Problem StatementOne problem, investigated three ways.
Leg 1
Occurrence
Why did it happen?
The specific, direct cause — why the defect was made.
Leg 2
Detection
Why did it escape?
Why our checks and controls did not catch it first.
Leg 3
Systemic
Why did the system allow it?
Why the process or management system permitted the gap.
Corrective & Preventive Action
Action(s) — make / detect / system
Verification of Effectiveness
How to use the three legs
Occurrence asks why the defect was created. Detection asks why it slipped past your controls. Systemic asks why the process or management system allowed the gap. Drive each leg to a process-level root cause, then close all three with one corrective-action plan — that's how a fix actually holds.