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Diving Deeper:: 6 Steps Beyond The 5 Whys
Diving Deeper:: 6 Steps Beyond The 5 Whys
6 steps beyond
the 5 Whys
Introduction
When an incident or accident occurs at your workplace, what do
you do to fix the problem?
A starting point might be to run with the 5 Whys process, whereby you
start asking questions – typically, at least 5 – about what happened.
Yet, while investigators could use the 5 Whys process as a starting point,
they may however soon see the need to take the investigation further.
A good first analysis…
but is it enough?
In some cases the 5 Whys’ linear nature can
cause people to jump to conclusions and fail to
arrive at the true cause or causes of an incident
or accident. While the 5 Whys technique can be
successfully used for very basic investigations, it
does have a few limitations which any investigator
should be aware of before using it.
Top tips
• Act quickly to gather as much information as you can
• The more evidence you can collect, the better
• Assign one person to the job of collecting evidence
• Don’t throw evidence away when cleaning up after an
incident… make sure you save it!
Assemble
the team
Assemble the team
Get the right people together – people with the knowledge and
experience to help you understand the problem.
Top tips
• Get management support to bring the people you need
to the team, for as long as is needed
• Appoint a skilled and experienced facilitator
• The number of people should reflect the complexity of
the incident
• You may need an independent expert
to join the team
Conduct the Root
Cause Analysis
Conduct the Root Cause Analysis
Your goal is to conduct the RCA as soon as possible after the incident or
accident occurs – so that the information is still fresh in people’s minds
and remains untainted.
Appoint a time and place for the investigation to occur, as soon as the
required group can be convened. Then, once the group meets, set basic
ground rules around respecting others’ opinions and encouraging an
open dialogue.
The first task in an RCA is to define the problem. Add context to the
problem by including information about when and where it happened,
and clearly articulate the significance of the problem. This will
determine the time and resources allocated to resolving it – and is an
important beginning. At the end of the day it will also constitute your
business case that you present to management for endorsement of your
recommendations.
Then, create your cause and effect chart. Collect information from all
the people in the room and organise it logically according to the process
that you are using.
With the help of the entire group, you will gain a clear picture of the
problem at hand. At the same time, you will see what is unknown – and
thus what requires further investigation.
Conduct the Root Cause Analysis
Top tips
• Follow the RCA process
• You don’t have to be the subject matter expert, so don’t
profess to be one
• Teamwork is key – value all participants’ contributions
• Keep asking “why” or “caused by” questions for as long as
you need to
• Don’t stop too soon with your questioning
Implement the solutions
(corrective actions)
Implement the solutions (corrective actions)
Top tips
• Give ownership of a solution to an individual, not a group
or department
• Assign a due-date for each corrective action
• Support people in their efforts to implement corrective
actions
Measure the success of
the corrective actions
Measure the success of the corrective actions
How much downtime have you avoided? How much money have
you saved? Measure the impact of your RCA and its subsequent
corrective actions.
Top tips
• Identify which key performance indicators are being used
to measure success
• Use ‘before and after’ figures to prove it
Advertise your
successes
Advertise your successes
Top tips
• Put the results on a poster in a prominent position
• Share the full report with all relevant stakeholders
• Share with the broader work community
• Quantify your successes in a way that is easy
for others to understand
Case Study
Now that you have a good understanding The RCA is then undertaken (Step 3).
of each of the 6 Steps Beyond the 5 Why’s, Clarification of the purpose of the
let’s refer back to the initial case study investigation, in this case preventing the
used to illustrate the 5 Why method and recurrence of the “Delay in loading the
how diving deeper beyond this method, train”, is the first step. Then context to
using the “6 steps”, can allow you to get to the problem is included by identifying
the root causes of a problem. “When” it occurred, “Where” it happened
and how “Significant” the problem is (for
If we were to initiate the “6 Steps”, a
example; damage to reputation, cost of
search for all relevant information would
any demurrage for delayed shipments
be undertaken. Statements, photographs
etc). Quantifying the costs will create an
and a search for all maintenance history
understanding of just how significant this
on the drive motor are all collected.
problem is.
(Step 1)
Action Caused by
Conveyor has stopped
Condition Caused by
STOP
Conveyor loads the train
Primary Effect Caused by
Delay in train loading
Condition Caused by
STOP
Only 1 Loading Conveyor
Condition
Caused by
6 hours to replace ?
drive motor
Condition Caused by
motor operating
Action Caused by
Action Caused by Condition Caused by
STOP Bearing seized
Conveyor has stopped Drive Motor Drives
conveyor
Action Caused by
Action Motor was overloaded Condition Caused by
Caused by Seized bearing overloads
Drive motor tripped out
motor
Condition
Caused by
Motor has overload STOP
protection
Condition Caused by
STOP
Conveyor loads the train
Primary Effect Caused by
Delay in train loading
Condition Caused by
STOP
Only 1 Loading Conveyor
Condition
Caused by
6 hours to replace ?
drive motor
This is before the team has even got to why the bearing has seized. Problems are rarely as
simple as they seem. We tend to want to do things simply however this comes at the cost of
good understanding. Whilst you may understand, it is possible that others will struggle to
follow your logic. If all the information is not put into play then you rely on assumptions and a
common interpretation, which is precisely why many misunderstandings occur.
Let’s explore further on why the bearing seized by adding to the existing chart.
Primary Effect
Bearing seized
Caused by
Action Condition
Caused
welding seizes STOP
Metal welded together by
the bearing
Caused by
Caused by
Caused by
Action Condition
Caused by
Metal expansion Minimal clearnace STOP
in bearing in bearing
Caused by
Caused by
Caused by
So what do we notice? The same problem has been explored, however the complexity and
detail of the problem has certainly increased. If you want to establish a comprehensive
understanding of the problem throughout the company, the 6 Steps Beyond 5 Why’s will allow
you to do this. A strong understanding of the problem will lead to implementing effective and
timely solutions. (Step 4)
Measuring the success of the corrective action will need to be undertaken after a period of
time to ascertain the success of the solutions. (Step 5)
Advertising success and sharing reports will create a positive dynamic within the company for
the support of the Root Cause Analysis program, whilst also educating all employees within
the company at the same time. (Step 6)
Conclusion
In this eBook, we looked at the 5 Whys process – and identified
that, in some cases, it does not get to the root causes of an
incident or accident.
onsite training
All our training courses are available for delivery onsite at your
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offers students the opportunity to work on a real life problem from their
workplace under the guidance of one of our experienced trainers.
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