How to proceed “Why-Why Analysis”

To identify the root cause

for quick improvement

- Recurrence prevention of root cause -

October 1st, 2003

Yazaki Corporation
Toyota Business Unit
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 1. Introduction
• Under the Toyota Production System, “Why-Why Analysis”
has an ironclad principle to repeat “Why” 5 times at Toyota,
in order to identify the root cause of a trouble.
• This principle shows it is very important to identify the root
cause and complete the recurrence prevention as quickly as
possible when a certain trouble occurs.
• These days, “Why-Why Analysis” brings about some
successful results in identifying the root cause of a quality
problem and implementing recurrence prevention.
• I sometimes hear such complaints, “I don’t understand how
to do Why-Why Analysis”, “I can’t repeat “Why” 5 times”,
or “I can’t identify the root cause because I’ve found many
possible causes”.
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• For people in need, I give you tips to proceed “Why-
Why Analysis” in this document.
I hope this document helps you understand and
utilize “Why-Why Analysis”.

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2. Before beginning Why-Why Analysis
(1) Clarify the content of a problem, and
understand the fact exactly.
Clear up the problem with 5W1H.
When Date, Time
Where Place, Process
Who Person, Responsible person
What Component, Part
Why Reason, Cause
How Method, Means, Frequency,
Condition 4
(2) Understand the structure (mechanism) and
function (role) of the problem.
Check drawings, QC process chart, Inspection specification,
Operation standard etc. to completely understand the parts,
characteristics, functions and structures.

(3) Check the problem part of defective products

and actual things of relevant parts.
When checking the defective products, it is necessary to keep
such pictures and data as dimensional accuracy and measured
characteristics etc.

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(4) Check the actual processing/assembly sites of
defective products or relevant parts.

On the day that the defective product is manufactured,

ask the supervisors and operators if they’ve found
some differences before/after the manufacturing, and
record the findings.
If changes in 4M (Machine, Material, Method, Man)
are found, record the details.

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 3. 5-time Why
If you ask “Why” only once, you cannot take a
permanent measure for recurrence prevention
because one-time “Why” provides superficial causes,
ending up first aid.

There are numbers of examples that repeating

“Why” 5 times has reached to the root cause, based
on the fact of actual product and production site in
an attempt to identify the root cause.

Followings are essential for the analysis.

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 Processing/Assembly conditions at the
production
site must be the same as those when the defect
product was manufactured.
It’s not too much to say that you can’t find out
the root cause if the processing/assembly
conditions are changed, because the existing
situation at the production site is also changed.
Processing and assembly must be checked right
after processed or assembled.
This is a very effective condition to identify the
root cause based on the fact.
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• Keep in mind that the more you are away
from the time when a defective occurred,
the more you have difficulty in identifying
the root cause.

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 4. Case study from Toyota
Production System
Here is a model case of “Why-Why Analysis”
for the phenomenon: “Machine does not work”

With 5-time “why”, Toyota identified the root cause.

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 Case study: “Machine does not work”
(1) “Why the machine stopped?”
Because the fuse blew out due to the overload.
(2) “Why the overload was applied?”
Because the lubricant for the bearing was not enough.
(3) “Why the lubricant was not enough?”
Because the lubricant pump did not pump up enough.
(4) “Why the pump did not pump up the lubricant enough?”
Because the axis of pump had looseness resulted from
abrasion.
(5) “Why the axis wore out?”
Because some swarf came in resulted from the fact that
there was no filter.
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 Repeating “why” 5 times, Toyota reached to the
countermeasure: “Install a filter”

As this example shows,

Phenomenon
You must confirm based
(result) on the principles.
1st cause
2nd cause
Machine
stopped. 3rd cause
Fuse blew
out due to 4th cause
Lubricant
the overload. 5th cause
was not
Pump didn’t
enough.
pump up Axis wore out.
enough. 12
Swarf came in.
• It is very important to stick to Genbutsu (actual
product), Genba (actual site), and Genjitsu (fact)
when you are trying to identify the root cause.

• If you come to deadlock, it is important to

- observe thoroughly.
- check if there are some problems with each
item and activity.
- cling to questions you may have.
- repeat “Why” until you are fully satisfied.
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 Let’s think about the following cases.
1) 1-time “why”
• The supervisor replaced the fuse. This is a good
measure as first aid. However, the same problem
would reoccur in a couple of months because the
measure is not taken for the root cause.

2) 3-time “why”
• The lubricant pump could be replaced. However,
the same problem would reoccur in a few months
because this measure is not taken for the root cause
as well. Also, the measure costs too much.
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3) 4-time “why”
• The axis of pump could be replaced. However, the
same problem would reoccur in a few months
because this measure is not taken for the root cause
as well. The cost would be cheaper than that in the
case of 2) above, but it takes long time to determine
the frequency of replacement.

4) 5-time “why”
• Permanent measure can be taken, and the machine
will never stop due to the same reason. Production
problems come to the end when recurrence
prevention for the root cause is completed.
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• In this way,
if you pursue “why” 5 times,
you can find out the root cause and can
take permanent measures.

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Now, if I repeat “why” further, followings come out.

(6) Why the filter was not installed?

Because the machine designer didn’t realize the
necessity of the filter.
(7) Why the designer didn’t realize?
- Because he/she had no thoughts about swarf.
- Because there was no system to feed problems
occurred at a plant back to the Equipment Design
Department.
(8) Why the designer didn’t realize the treatment of swarf?
Because he/she didn’t care about issues other than the
conditions for product processing.
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• In this case,
“Why-Why Analysis” is not focused on the
relationship between “result and cause” with
actual product and production site, but on the
designer or system. In other words, this
analysis is far away from the original purpose
that is to take the recurrence prevention of root
cause.

If it is necessary to improve the system, an

appropriate department at the head quarter
must be in charge and enhance the system. 18
5. Notices on “Why-Why Analysis”
When analyzing, identify the cause from both
aspects of “made the problem occur” and “made the
problem flow out”.
To figure out if you reach the root cause or not,
confirm that the problem will never occur due to the same
cause.
It is quite unusual that one phenomenon (Why) is caused
by two causes at the same time.
Production problem should be solved by identifying root
cause in production process errors but not as design errors.
Do not take up an assumed cause which is not found
from the fact.
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 Sentences to specify “phenomenon” or “Why”
must be simple and short.

After finishing the analysis, read the report from

the last “Why” to the first “phenomenon” with
using the conjunction of “thus”, in order to
confirm that the analysis makes sense, is
reasonable, and does not have any leaps in logic.

Why Thus, Why Thus, Why Thus, Phenomenon

Swarf came in. Axis wore out. Fuse blew out.

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When continuing “Why”, stop analyzing a
possible cause if you could determine, based on
the investigation of actual products and
production site, that a phenomenon is not caused
by the possible cause.

Do not find causes in human mentality.

Ex: The operator was out of mind.
The operator was tired.

Do not use the word of “bad” and unclear words

in the sentences.

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