Aula 6 - 5 Porques

3x5 Why Supplier Training
CONFIDENTIAL AND PROPRIETARY:

This copyrighted document is the property of the ZF Group. This document and the information contained herein are disclosed in confidence and may not be copied, disclosed to others,
or used for any purpose, without the prior written consent of the ZF Group. © ZF Friedrichshafen AG, 2017
Contents
1) 5 Why and 3x5 Why

2) ZF Problem Solving Process
3) The Three Legs
4) Template
5) The Logic
6) Examples

This copyrighted document is the property of the ZF Group. This document and the information contained herein are disclosed in confidence and may not be copied, disclosed to others, © ZF Friedrichshafen AG 2
5 Why
5 Why is an iterative question asking strategy used to make the connection between the cause
and effect of a particular problem.
Problem: Fastener was not tightened.
Why?: Screw bottomed out in the hole
Why?: Hole is too shallow
Why?: Drill bit was broken
The primary goal is to determine the root cause by repeating the question "Why?“ Each answer
forms the basis of the next question.
The "5" in the name was based on the number of questions typically required to understand the
root cause beginning with a statement of the problem. More or fewer may actually be required.

5 Why
When we think about “root cause” we are typically thinking about “What caused the problem or
defect?”
In reality, there are usually more than one “cause” or “factor” that was responsible for the problem to
occur.
We can keep asking Why and eventually we get into areas that are non-technical in nature, and
“allowed” the problem to occur.
We can break down these “causes” into three areas to help us better understand how the problem
occurred, and what needs to be fixed in order not to have the problem happen again.

3x5 Why
3x5 Why is the way we can break this down into easy to manage paths.
We will consider three paths, or “legs” when asking “Why?”
They are:
1. Specific Cause Leg

2. Detection Cause Leg
3. Systemic Cause Leg

3x5 Why
3x5 Why is not a stand alone root cause problem solving tool.
It is a problem solving strategy or documentation process that is used to guide the

thought process and communicate the link between the Problem and the Root
Causes on the shop floor and in the Quality Management System by answering
consecutive WHY’s.
The tools used to answer the WHY’s are varied and could include anything from
simple observation and symptomatic knowledge, to advance problem solving
strategies and tools.

or used for any purpose, without the prior written consent of the ZF Group. © ZF Friedrichshafen AG, 2017 © ZF Friedrichshafen AG 6
ZF Problem Solving Process
Issues 8D – Problem Solving The ZF problem solving process begins

with the 8D.
1) D1 Team
2) D2 Defect description (s)

This documents the actions beginning
with team identification and ending
3) D3 Containment action (s)
with team recognition once the
Customer/ Internal / 4)D4 Root Cause (s) problem has been eliminated. What
Supplier Issues 5)D5 Chosen permanent corrective action (s) happens in between D1 and D8, can
from QSYS & Other vary greatly depending on who is
6) Corrective action effectiveness control
sources D6
7) Long term action to prevent reoccurrence managing and/or solving the particular
D7
problem. Many different strategies
8) Team and Individual Recognition
D8 and tools may be employed. The 8D
can be used on any type of problem,
both technical and non-technical.

or used for any purpose, without the prior written consent of the ZF Group. © ZF Friedrichshafen AG, 2017 © ZF Friedrichshafen AG
8D – Problem Solving
1) D1 Team The standard problem solving root cause

documentation is the 3X5 Why.
3 X 5 Why
This documents the link between the
4) D4 Root Cause (s)
1 Technical Leg
problem statement and the root causes of:
5) D5 Chosen permanent corrective action (s)
2 Detection Leg
6) D6 Corrective action effectiveness control 3 Systemic Leg • Why Made
7) D7 Long term action to prevent reoccurrence
Answer D4, • Why Shipped
D5 & D7 • Why Not Predicted in APQP
8) D8 Team and Individual Recognition
process.
It does not define the tools or

methods for diagnosing the root
cause.
8D – Problem Solving
1) D1 Team

3 X 5 Why Tool Box
4) D4 Root Cause (s) Problem Solving

1 Technical Leg
5) D5 Chosen permanent corrective action (s) 2 Detection Leg Stategies, Tactics
3 Systemic Leg and Tools as
6) D6 Corrective action effectiveness control
Answer D4, appropriate to
7) D7 Long term action to prevent reoccurrence D5 & D7 specific problem
8) D8 Team and Individual Recognition
Root Cause Problem Solving Processes and Tools are varied, and
can include anything from simple observation and systemic
knowledge, trial and error, to advanced Problem Solving
strategies and tools

The Three Legs
Three 5-Why legs will lead to three or more Root Causes and
therefore three or more Corrective Actions
Specific Root Why did the problem occur?

WHY?
Cause Leg Why was failure mode created? WHY?
Specific Root Cause WHY?
WHY?
Root
WHY? WHY?
Why were existing controls not
Cause
Detection Root WHY?
Cause Leg sufficient to catch the problem
before WHY?
it escaped? WHY?
WHY? WHY? Root
Systemic Root Why did our Quality systems not WHY? Cause
Cause Leg protect the customer? WHY?
WHY?
WHY? Root
May require more or fewer than 5 Why’s Cause
The Three Legs
WHY?
Manufacturing System
WHY?
WHY? What CA will be implemented to
prevent the failure mode from being
WHY? created
“Specific”
WHY? Root Cause “Prevent” Corrective Action
WHY?
WHY?
Quality System
What CA will be implemented to
WHY? insure that if the failure mode is
WHY? created, it will be detected before it
“Detection” leaves the plant
WHY? Root Cause
WHY? “Protect” Corrective Action
WHY? APQP System
WHY? What CA is required in the QMS to
WHY? ensure the Specific and Detection
“Systemic” Failure modes will not happen in the
WHY? Root Cause future
“Predict” Corrective Action
The three legs
If we get these root causes wrong then the corrective

WHY? actions will not address the proper “prevent”, “protect”
WHY? and “predict” causes. We may miss one.
WHY?
WHY?
“Specific”
WHY? “Prevent” Corrective
Root Cause
WHY? Action
WHY?
WHY?
WHY?
“Detection”
WHY? Root Cause
“Protect” Corrective
WHY? Action
WHY?
WHY?
WHY? “Systemic” “Predict” Corrective
WHY? Root Cause Action
Pitfalls
Potential Pittfalls
•Results are not repeatable - different people using 5 Whys come up with different
causes for the same problem. Because other problem solving tools must be used,
fishbone, 8D, is/is not, etc, the tools chosen may be different.
•Tendency to isolate a single root cause, whereas each question could result in many
different root causes.
•The method provides no hard and fast rules about what lines of questioning to
explore, or how long to continue the search for additional root causes. Thus, even
when the method is closely followed, the outcome still depends upon the knowledge
and persistence of the people involved.
© ZF Friedrichshafen AG
Who to Involve
Floor level
-Production
Specific Root Cause
-Skilled Trades Detection Root Cause
-Material
People doing the
Control
How was the problem work
-1st Line How did the problem escape?
created?
Supervisor
Support
-Management Systemic Root Cause
People who set up
-Purchasing Why weren’t our and Quality Management Systems robust enough
the processes
-Engineering to adequately predict the failure and protect the customer?
-Procedures
and policies
Structuring a “5 Why”
“What is wrong with what?”
Problem Statement
Object Defect
Bill was late Why?
for work The front right rotor is cracked.
Why? The steering gear leaked.
Bill’s car Bill is late for work.
Therefore didn’t start
The battery Why?
Therefore
was dead
Dome light Why?
was on all
Therefore night
Car door Root
was left
ajar Cause
Therefore

ZF 3 x 5 Why Template (QSYS)
These are tied

directly to root
causes identified
in each leg.
If we get the root

cause wrong for
each leg, the CA
will be wrong.

Supplier VIN Template
A 3x5 Why
Template is
available in VIN
for suppliers.

Supplier VIN Example
Open and review

template

Finding Root Cause
1. Each answer to the why question must be based on data and observation.
➢ Don’t sit around and guess what you think happened. “Go and See” collecting
data and documenting observations while working down the causal chain.
2. A good practice when reviewing a 5 Why is to ask the problem solving team how the
why answer was found and/or how was it verified.
3. The why statements need to be precise and clearly stated based on the data and
observations.
➢ Imprecise wording can mask potential causes or waste time going down the
wrong path.
4. Avoid taking big steps or jumping down the causal chain.

➢ This can easily be detected using the “therefore” logic test.

Logic of the 3 legs
Problem as customer Keep asking “Why?” until root cause is reached.
sees it. “What” is Typically within 5 Why’s, may be fewer or require more.
wrong with “What”?
•Unit is Leaking Why did customer experience the problem? - Will
•Vehicle set Fault Code Part Failure mode typically be one or two Why’s from customer
•Pump is Noisy as created in the problem. Usually this will be the failure mode in the
plant. product.
•Fastener not tightened
Why? • step in bore
Specific Cause Leg • i.d. out of spec.
Why? • threads oversized
•Missed operation
Why?
Therefore
Why? What in the process
Therefore
happened to create the
“Specific” failure mode.
Therefore Root
Root Cause •chip in tool holder (if the failure
Read the leg backwards, but stating “therfore” instead of Cause mode is bore too large)
asking WHY? Therefore • contamination on seal (if
Problem is leak)
Each step back must make sense with the statement •Machined part re-loaded to
“therfore”. machining center (if failure mode
is oversize threads)
Logic of the 3 legs
Failure mode The Failure mode becomes the first box of

as created in the detection leg. We need to
the plant understand why once the failure mode
WHY? was created, why it was not detected.
WHY?
WHY?
Detection Cause Leg WHY?
Why?
Failure WHY?
Mode Why?
Why?
Therefore
Why?
Therefore •No detection in place for
“Detection” failure mode
Therefore Root Root Cause
•Gage out of calibration
Cause
Therefore
•Part bypassed inspection due
to non-standard work
Logic of the 3 legs
We can go a step deeping into Detection.
We addressed why the failure mode was not detected.
We can also ask why the Specific Root Cause was not detected. In other
Failure
words, why did we not detect the condition or event that allowed the
Mode failure mode to be created. .
Detection Cause
Leg
Specific
Root Root
Cause Cause
“Detection” •Load Monitoring not available

Root Root Cause with current control system.
Cause
•Chip Detection in tool holder
not in place.
Logic of the 3 legs
The Systemic Cause Leg will typically begin with either the
Specific or Detection Root causes and in most cases it is “Specific”
appropriate to include legs for both. Two Systemic Root Root Cause
Cause Legs can be shown.
Why?
Systemic Cause Leg Root “Detection”
Causes Why? Root Cause
Why?
Therefore
Why? •Operator training matrix was
Therefore
not reviewed prior to assigning
Root “Systemic” operator to cell.
Therefore
Root Cause •Specific root cause was not
Cause included in PFMEA when
Therefore
additional machine added to
cell.

23
Specific Root Cause Leg
Specific Root Cause: WHY did the problem occur?

•Begin this leg with the problem as the customer observed it.
•Answering the next WHY should be supported by data, not opinion
•Do not speculate, jump steps, combine steps or assume cause is obvious.
•Include the failure mode (symptom) that was created in the plant.
•Keep to specific technical reasons - What caused the failure mode?
•Will addressing/eliminating the specific root cause prevent recurrence. If not, go down another Why.
•Should end at the point the problem can be turned on and off. (again, data must support)
•Should not include items like “poor operator training”, “poorly defined work instructions”,
“operator played on mobile phone”, “test not robust”,….etc
•Systemic and detection reasons are not included.
•All paths must make sense reading backwards with “therefore” instead of “why”

Detection Root Cause Leg
Detection root cause: “Why were existing controls not sufficient to

catch the problem before it escaped?”
•Begin with the Failure mode as created in the process.

•Focus on inspection system for the failure mode (symptom)
•Did we inspect for the failure mode?
•If yes, how did it fail to detect the failure mode?
•If no, then move on to system root cause and address
•Consider another leg to find the root casue of the failure mode detection
•Why did the process not detect the condition or event that allowed the failure mode
to be created.

Systemic Root Cause Leg
•Systemic root cause: Why did our systems not protect the
customer?
•This is the most important leg as nearly all failures point back to some failure of our Quality
Management process.
•Put the Specific Root Cause and/or the detection root cause in the first box
– both may need to be addressed
•What in our design or PFMEA did not consider the potential failure cause?
•How did our APQP fail to consider this?
•If process or control plan included detection method, but was ineffective, Why? Gage
Calibration procedure not followed,or calibration not completed. Did operator training
materials not include specific instructions that would have prevented the failure. Cannot
simply state “operator training” as a root cause. It ALWAYS goes deeper than this.
•May be multiple Systemic issues to consider.

Is this a Good or Bad “Specific Cause” Leg?
Missing o-ring
on part number Why
K10001J To check your reasoning, should
Parts missed the o- make sense going backward by
ring installation stating therefore. If this doesn’t
process make sense, rethink the Why.
Therefore Why
Parts had to be Why

Therefore
reworked
This is not why they missed the Operator did not
install process. Rework parts return parts to the
can correctly go through the proper process step Why
process after rework
Therefore
No standard rework
procedures exist
Therefore
Missing o-ring
on part number Why This is a systemic failure
K10001J and needs to be
Parts missed the o- addressed, but it’s not the
ring installation Why root cause. This will lead
process to CA being tied to system
Therefore rather than specific root
Parts had to be Why casue.
reworked
Therefore Operator did not
return parts to the
proper process step Why
Therefore
after rework
No standard rework
procedures exist
Therefore
CONFIDENTIAL AND PROPRIETARY: 29
Is this a Good or Bad “Detection Cause” Leg?
Missing threads on
fastener part number
LB123
Why
Did not detect Why

Therefore threads were
missing
Sensor to detect thread
Why
presence was not
working
Therefore Sensor was Why
damaged
Therefore No system to
assure sensors are
working properly
Therefore

This is a systemic failure and
Missing threads on needs to be addressed, but it’s
fastener part number Why not the root cause of not
LB123 detecting the failure This can
lead to missing a CA on the
Did not detect actual root cause
threads were Why
Therefore missing
Sensor to detect thread
presence was not Why
Therefore working
Sensor was Why
damaged
We can go a step deeper into Therefore No system to
why the sensor was damaged assure sensors
if possible. are working
properly
Therefore
Why Review and determine if :
Bracket joint 1. Any of the Why’s could be answered
failed to meet differently?
torque 2. Does this end at the root cause?
Threads 3. Are Systemic or detection causes
Why included?
stripped
during 4. Any other errors in path?
Therefore torque
Why
operation
Threads out of
spec. due to Why
going through Process mapping
tapping op. twice and material flow
Therefore
is confusing to Addition of relief
new operators operators with
inadequate experience
Therefore resulted in parts going
through tapping twice
Therefore
Should be broken out into two
Why separate Why’s. Remember,
Bracket joint Why
don’t lump too much Threads out
failed to meet
information together or skip of spec.
torque
steps in logic.
Threads Went through
Why
stripped tapping twice
during Therefore
Therefore torque
Why
operation
Threads out of
spec. due to Why
Why
Fastener joint
failed to meet Operator place
torque These are systemic previously
problems, not what tapped parts into
Threads actually happened to tapping station
Why
stripped create the failure
during This is the action
Therefore torque that “caused” the
Why
operation parts to be out of
Threads out of spec.
spec. due to Why
Therefore
Why
Bracket joint
failed to meet
torque
Threads A corrective action on the “specific”
Why
stripped root cause will prevent parts from
during being placed into tapping operation
Therefore torque
twice.
operation Why
Threads out
of spec. (too Why
large).
Therefore Went through
tapping twice
Operator place
Therefore previously
tapped parts into
tapping station
Therefore

Threads out 1. Any of the Why’s could be answered
of spec. (too differently?
large). 2. Does this end at the root cause?
Existing process 3. Any other errors in path?
controls did not Why
prevent operator
Therefore from placing parts
into tapping twice
Machining center
did not have
controls to detect
Therefore previous tapped
part

Why
Threads out
of spec. (too
large).
X
Existing process
prevent operator
into tapping twice
Machining center did
not have controls to
This is the detection leg, detect previous
but we find the word Therefore tapped part
prevent

Why
Threads out
of spec. (too
large).
Existing process
prevent operator
into tapping twice
Machining center did
not have controls to
detect previous
Therefore tapped part
and
Parts are not
measured to verify
after tapping
Why
Threads out
of spec. (too
large).
Machining center did Corrective action #1 would address detection of
not have controls to previously tapped parts being placed into
detect previous machining center.
Therefore
tapped part
Parts are not Correction action #2 would address detecting a

measured 100% part that has been tapped twice from being
after tapping to shipped to customer or next operation
verify dimensions

Is this a Good or Bad “Systemic Cause” Leg?

Operator place 1. Any of the Why’s could be answered
previously tapped differently?
parts into tapping 2. Does this end at the root cause?
station 3. Any other errors in path?
APQP/FMEA did
not consider Why
double tapping a
risk
Therefore
No prior customer
returns for
Therefore threads tapped
twice

Is this a Good or Bad “Systemic Cause” Leg?
Why
Operator place
previously tapped
parts into tapping This is not the only factor in
station deciding on if a failure mode
APQP/FMEA did exists. We need to consider our
Specific root not consider Why APQP system, and how we
cause double tapping a determine and evaluate risk(
considered but risk RFMEA, lessons learned, read
not detection Therefore across, ….)
No prior customer
returns for
Machining center Therefore threads tapped What corrective action will be
did not have twice considered for systemic root cause
controls to detect Why related to specific root
previous tapped cause?.......Process standards, etc,
What corrective action will be RFMEA required for all equipment
part ……….
considered for systemic root cause
related to detection?
Examples of Systemic Root Causes
System root causes may be considered those things we must update in procedures, documentation, APQP, and standards,
to ensure that what was learned is captured so it cannot happen on other products, other lines, future products and
processes. The development process missed something which allowed the original failure to happen. How will we ensure
we don’t miss it again?
 Process steps not robust or followed:  Process controls inadequate

– PFMEA – SPC limits / sample size
– Process Flow Diagram – Process capability
– Control Plan – Operator work instructions
– Changeover process / procedure – Lot traceability
– Preventative / Gage Maintenance
– Error and Mistake Proofing
– Reaction Plans / Escalation.

Examples of Systemic Root Causes
 Quality system non-conformance

– Improper changeover
– Inadequate control of non-conforming product
– Failure to act on early warning
– Failure to follow procedures
 Change management
– Change process not followed
– Customer not properly informed
– Documentation not updated prior to implementation (D/PFMEA, Control Plan, Work Instruction)
Remember this leg helps prevent repeat problems from occurring in the future!
Additional Exercise
As an added enhancement to this review, please consider one recent problem in your
plant and try to create a 3x5 why from your knowledge of the root cause.
Please be sure to consider all legs.
You may make specifics of your problem generic as to protect any sensitive information.

Thank You
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information including the right to file industrial property right applications and
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3x5 Why Supplier Training

CONFIDENTIAL AND PROPRIETARY:

1) 5 Why and 3x5 Why

CONFIDENTIAL AND PROPRIETARY:

CONFIDENTIAL AND PROPRIETARY:

CONFIDENTIAL AND PROPRIETARY:

We will consider three paths, or “legs” when asking “Why?”

1. Specific Cause Leg

CONFIDENTIAL AND PROPRIETARY:

It is a problem solving strategy or documentation process that is used to guide the

CONFIDENTIAL AND PROPRIETARY:

Issues 8D – Problem Solving The ZF problem solving process begins

2) D2 Defect description (s)

CONFIDENTIAL AND PROPRIETARY:

1) D1 Team The standard problem solving root cause

It does not define the tools or

2) D2 Defect description (s)

4) D4 Root Cause (s) Problem Solving

CONFIDENTIAL AND PROPRIETARY:

Specific Root Why did the problem occur?

If we get these root causes wrong then the corrective

CONFIDENTIAL AND PROPRIETARY:

These are tied

If we get the root

CONFIDENTIAL AND PROPRIETARY:

CONFIDENTIAL AND PROPRIETARY:

Open and review

CONFIDENTIAL AND PROPRIETARY:

4. Avoid taking big steps or jumping down the causal chain.

CONFIDENTIAL AND PROPRIETARY:

Failure mode The Failure mode becomes the first box of

We addressed why the failure mode was not detected.

“Detection” •Load Monitoring not available

CONFIDENTIAL AND PROPRIETARY:

Specific Root Cause: WHY did the problem occur?

CONFIDENTIAL AND PROPRIETARY:

Detection root cause: “Why were existing controls not sufficient to

•Begin with the Failure mode as created in the process.

CONFIDENTIAL AND PROPRIETARY:

CONFIDENTIAL AND PROPRIETARY:

Parts had to be Why

Did not detect Why

CONFIDENTIAL AND PROPRIETARY:

Why Review and determine if :

CONFIDENTIAL AND PROPRIETARY:

CONFIDENTIAL AND PROPRIETARY:

Parts are not Correction action #2 would address detecting a

CONFIDENTIAL AND PROPRIETARY:

Why Review and determine if :

CONFIDENTIAL AND PROPRIETARY:

 Process steps not robust or followed:  Process controls inadequate

CONFIDENTIAL AND PROPRIETARY:

 Quality system non-conformance

Please be sure to consider all legs.

CONFIDENTIAL AND PROPRIETARY:

ZF Friedrichshafen AG behält sich sämtliche Rechte an den gezeigten

1/26/2018 | 3x5why © ZF Friedrichshafen AG 45

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