Quality

5 Why Analysis

Just a problem can be fixed if

you can turn on and off
 5-Why Training Agenda

• Understanding of 5-Why

• Quick 5-Why Exercise as a group

• Critique Sheet

• 5- Why Examples

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 Is the powerful question… own it!!
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 Power of Asking Questions

How
Speed How Fast
Limit Fast Should
Strictly Are You You Be
Enforced Going? Going?

No Cause Cause
Reaction Reaction Reaction & Research
(Look at speedometer) (Look at speedometer;
Search for speed limit sign)

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 Power of Asking Questions

Who are the best at asking questions to

solve problems?

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 Power of Asking Questions

Children!
Why?
…because they keep asking objective, open-ended questions until
the answer is simple and clear

When working with people to solve a problem,

it is not enough to tell them what the solution is. They
need to find out and understand the solution for
themselves. You help them do this by asking open-
ended , thought provoking questions.
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 Close-Ended vs. Open-Ended Questions

Close-Ended: Structures the response to be answered

by one word, often “yes” or “no”. Usually
gives a predetermined answer.
Example: “Did the lack of standardization cause the incorrect setup?”

Open-Ended: Leaves the form of the answer up to the

person answering which draws out more
thought or research.

Example: “How is setup controlled?”

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 Benefits of Open-Ended Questions

 Requires thought
 Promotes additional research
 Enhances problem solving skills
 Does not assume there is one right answer
 Avoids predetermined answers
 Stimulates discussion
 Empowers the person answering

In many circumstances, it is not only the answer itself,

but the process by which the answer was determined
that is important when asking an Open-Ended question

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 More Examples
Example 1: “Did the lack of a PM system cause this tool to break?”
(Close-Ended question, can be answered by a “yes” or “no”, gives the
person a predetermined answer that PM is to blame)

“What could have caused the tool to break?”

(Open-Ended, probing question forces the person to think about all
possibilities, not just PM)

Example 2: “Would improving material flow help reduce lead times?”

(Good question but it’s still Close-Ended, focuses the person on material
flow as a means to reduce lead time. Is this the best improvement?)

“What are some options on improving lead time?

(Open-Ended, triggering more thought and research on all variables
impacting lead time.)

Example 3: “Is equipment capability causing the variation in your process?

(Close-Ended, can be answered by a “yes” or “no”, focuses the person on
equipment being the source of variation)

“What could potentially cause variation in your process?

(Open-Ended, triggering more thought and research, opens up possibilities
of variation with man, material & method, not just machine)

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 5 Why
Overview

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 5-Why Analysis Three Paths

5-Why:
 Specific problem:
– Why did we have the problem?
 Problem not detected:
– Why did the problem reach the Customer?
 System failure:
– Why did our system allow it to occur?

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 5-Why Analysis

ifi c
ec
Sp

n
ctio
ete
D

m ic
ste
Sy

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 Root Cause Analysis

Delco fuse box

Insert example

What tool do
We use for this?

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 Grasp the Situation

• Part I – Grasp the Situation

– Step 1: Identify the Problem
• In the first step of the process, you become aware of a problem that may be
large, vague, or complicated. You have some information, but do not have
detailed facts. Ask:
• What do I know?
– Step 2: Clarify the Problem
• The next step in the process is to clarify the problem. To gain a more clear
understanding, ask:
• What is actually happening?
• What should be happening?

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 Grasp the Situation

– Step 3: Break Down the Problem

• At this point, break the problem down into smaller, individual elements, if
necessary.
• What else do I know about the problem?
• Are there other sub-problems?

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  Grasp the Situation

– Step 4: Locate the Point of Cause (PoC)

• Now, the focus is on locating the actual point of cause of the problem. You need
to track back to see the point of cause first-hand. Ask:
• Where do I need to go?
• What do I need to see?
• Who might have information about the problem?

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  Grasp the Situation

– Step 5: Grasp the Tendency of the Problem

• To grasp the tendency of the problem, ask:
• Who?
• Which?
• When?
• How often?
• How much?
• It is important to ask these questions before asking “Why?”

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 5-Why Analysis

• Step 1: Problem Statement

– Is the problem statement clear & accurate?
– Is the analysis on the problem as the customer sees it?

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 5-Why Analysis

• Step 2: Three Paths

– Are all three legs filled in?
– Are there any leaps in logic?
– Can you ask one, two, or three more Whys?
– Is there a cause-and-effect relationship in each path?
– Can the problem be turned “on” and “off”?
– Does the path make sense when read in reverse?
– Do the whys relate to the actual error?
– Does the non-conformance path tie to design, operations, dimensional issues,
etc.?
– Does the detection path tie to the customer, control plans, etc.?
– Does the systemic path tie to management issues or quality system failures?

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 5-Why Analysis

• Step 3: Corrective Actions

– Is there a separate action for each root cause?
– Is it possible to implement each corrective action?
– Do corrective actions require Customer approval? If so, how will they be
communicated to the Customer?
– Is there evidence to support verification of corrective actions?
– Are corrective actions irreversible? If not, do actions address ongoing
containment?
– Is there a plan to standardize lessons learned across products, departments, etc?

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 5-Why Analysis

• Step 4: Lessons Learned

– How could the problem have been foreseen?
– How will information be implemented?
• On the line or in the plant?
• At the point of detection?
• Cross functionally at the Supplier?
• Other products/plants?

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 5-Why Analysis

• Step 5: Overall
– Are there gaps or “holes?”
• Are there things missed or not documented?
– Do corrective actions address actions the Supplier owns?
– How many iterations of 5 Why Analysis have there been?
– Who prepared the 5 Why Analysis?
• One person?
• Sales representative ?
• Clerk?
• The best answer is a cross functional team that understand the product and
process!

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 Therefore Test

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 5-Why Analysis

The problem is stated through

Problem the eyes of the customer

The first why is the main cause

The second why is what causes

Th
the main cause

er
ef
Etc.

or
W

e
hy
?

Etc.
You have root cause if you
Root Cause can demonstrate:
• cause on, problem on
• cause off, problem off

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 5-Why Example
(Non-conformance)

Problem Cookies taste really bad

Cookies are undercooked

Th
er
Ingredients are wrong

ef
or
W

e
hy

Used goose eggs rather than

?

chicken eggs

Root Cause Recipe did not specify bird type

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 5-Why Example - Business Plan
(Non-conformance)

Problem Did not meet the annual business

plan goal of a 10% increase in sales

Did not thoroughly evaluate

Th
market/competition

er
Did not have adequate

ef
resources

or
W
hy

e
Did not anticipate required
?

resources

Did not develop a plan as to

Root Cause “how” the goal would be reached

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 5-Why Example - Business Plan
(Detection)

Did not meet the annual business

Problem plan goal of a 10% increase in sales

Did not know the goal was not

going to be met

Th
er
Did not evaluate the status of

ef
the goal until December

or
W
hy

e
Did not have alarms limits
?

identified at strategic intervals

(monthly, quarterly, etc.)

Root Cause Did not develop a plan to monitor

the status of reaching the goal

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 A good 5-Why will answer “Yes” to the five
PDCA questions:
“A problem well defined
is a problem half solved”

ACT
Standardize
PLAN
Understand the problem

5. Has a plan been identified 1. Is the problem statement

to STANDARDIZE and take
all lessons learned across
products, processes,
plants, functional areas, etc.?
CLEAR and ACCURATE?
2. Has the SYSTEMIC
root cause(s) been
identified for all legs?

CHECK
Follow-up
DO
Execute the Plan

4. Has a plan been identified 3. Has IRREVERSIBLE

to verify the CORRECTIVE ACTION(s)
EFFECTIVENESS been implemented for
of all corrective ALL root causes?
actions?

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 5-Why Critique Sheet

• General Guidelines: A.) Don’t jump to conclusions!; B.) Be absolutely objective. C.) Don’t
assume the answer is obvious. D.) If you are not thoroughly familiar with the process
yourself, assemble a cross-functional team to complete the analysis.

• Step 1: Problem Statement

Is the analysis being reported on the problem as the Customer sees it?

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 5-Why Critique Sheet

• Step 2: Three Paths (Dimensional, Detection, Systemic)

-Are there any leaps in logic?
-Is this as far as the Whys lead? Can you still ask one, two, three more why’s)?
-Is there a true cause-and-effect path from beginning to end of each path? Is there
statistical data/evidence to prove it? ---Can the problem be turned off and on?
-Does the path make sense when read in reverse from cause to cause? (e.g.—We did
this, so this happened, so this happened, and so on, which resulted in the original
problem.)
-Do the why’s go back to the actual error?
-Does the systemic path tie back to management systems/issues?
-Does the nonconformance path ties back to issues such as design, operational, tiered
supplier management, etc…?
-Does the detection path ties back to issues such as protect the customer, control plans,
etc…?

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 5-Why Critique Sheet (cont)

• Step 3: Corrective Actions

-Does each corrective action address the root cause from a path?
-Is there a separate corrective action for each root cause? If not, does it make sense that
the corrective action applies to more than one root cause?
-Is each corrective action possible to implement?
-Are there corrective actions that affect the Customer or require customer approval? How
will they be communicated to the Customer?
-Is there evidence and documentation to support the validity of the corrective actions?
-Are the corrective actions irreversible? If not, are there corrective actions in place that
address containment?

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 5-Why Critique Sheet (cont)

• Step 4: Lessons Learned

-How could this problem have been foreseen?
-How will this information be implemented:
a.) on the line or in the plant?
b.) at the point of detection?
c.) cross-functionally at the Supplier?
d.) other product/plants?
-Are there lessons learned for the Customer?

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 5-Why Critique Sheet (cont)

• Step 5: Overall
-Do there seem to be big holes where ideas, causes,
corrective actions, or lessons learned are being avoided?
-Where things are missed or not documented?
-Do the corrective actions address the actions the supplier owns?
-How many iterations has the supplier gone through so far in preparing
this 5-why (It doesn’t happen on the first try!)
-Who prepared the 5-why?

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 Generic Information for 5-Why Example:
Regular Cola Soft Drink vs. Diet Cola

 The plant received a PR/R from a customer. (We use 5-Why Analysis to answer every
PR/R.)
 The PR/R states that the customer received “Regular Cola in the right container (same
for both products) with the Diet Cola label”. The order called for Regular Cola.
 The plant has two identical lines that are capable of running either of our two products.
The lines are located immediately beside each other. The only differences in the
products are the syrup and the labels.
 The plant runs both lines 24 hours per day. There are three shifts that run 7:00 a.m. to
3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m.
 The date code indicates that the defective product was manufactured at 3:03 p.m.
 Defective product has been contained and sorted.

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 Bottling Process Flow for 5-Why

BOTTLES B LIDS

O
T
T
WATER INSPECT
L
I
N
SYRUP G LABELS

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 5-Why Analysis: Cola
Example – Path A

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 5-Why Analysis: Cola
Example – Path B

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 5-Why Analysis: Cola
Example – Path C

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