Please read the three articles:

1. The 5 Whys Handbook

2. The 5 Whys Tool
3. The 10 Commandments of Visual Thinking

Then please use the tools to resolve one of your own problems. This is designed to strengthen
the effective problem solving skills learned through the articles listed above. Students will work
alone intimately engaging a problem related to their personal life or something that was
mentioned in the show.

The Intimate Engagement Project must follow the following steps:

1. Identify a problem or challenge in your life.

2. Keep a journal of your reflections and progress. Describe how you have been approaching it.
Has your approach been working? Note which problem solving skill you applied to your
problem and whether it was effective. This will be the contents of your journal.

3. Use scientific method and the idea of intimate engagement to clarify/solve the problem or
challenge you've chosen.

4. Once the project begins you should be writing in your journal at least 4 entries a week. The
particular problem you chose doesn’t necessarily have to be solved by the end of the project,
it’s the journey that matters.

5. The end result should be a paper (3-5 pages) describing the process. Additionally, you will
present an artistic rendering/demonstration of the problem.
earn how to find root causes of a problem by using 5-why analysis, so you can fix the issues where it
matters most. First in a series of four articles explaining this powerful tool.

By Karn G. Bulsuk

More information: 5-why Analysis using a Fishbone Diagram, 5-why Analysis using an Excel
Spreadsheet Table and The Weaknesses of 5-Why
5-why analysis, used throughout the kaizen concept and in quality control, is a tool to discover the root causes
of a problem.

More often than not, people fix a problem by dealing with issues that are immediately apparent. While it may
provide a quick fix, the problem tends to rear its ugly head in the same form, or with a different face later on.
Fixing the problem by nipping it in the bud is what all leaders and associates should aim to do.

For example, suppose we had a tree which was wilting and dying. We could make it look better in the short run
by cutting the wilted leaves, but surviving leaves will continue to wilt and the tree would still be dying

Instead, we need to investigate the cause of the wilting. Did we water the tree recently? Are there tell-tale signs
of fungi, bacteria or perhaps termites? Once we know the true issue, then we can fix it.

Most people get stuck in the Do-Do-Do-Do cycle, in which they carpet bomb every possible solution with no
guarantee that they will fix the true problem, wasting time, effort, and often money. 5-why analysis provides the
tool to engage in precision targeting to fix the right problem in one go.

Using 5-why
 The concept of 5-why is simple:

1. Identify the problem.

2. Ask yourself: why did this happen? Come up with all the causes you can think of.
3. For each of the causes you just identified, ask “why did this happen?” again.
4. Repeat until you’ve done steps 2 and 3 for five times. You should have identified the root cause by this stage.
5. Find solutions and countermeasures to fix the root cause.
You can also take a look at the 5-why flow chart above to the right, or download the PDF version for a closer
and clearer look.

How to Perform 5-why

More information:

• 5-why analysis using a fishbone (or Ishikawa) diagram

• 5-why analysis using a table
Imagine that you just finished organizing a Gala Dinner, and you had a problem in which the catering service
delivered the food 2 hours behind schedule. To find the root causes, we would do the following:

Step Reason Why?

1 The caterer delivered food 2 hours late. Why did this happen?
Why was the purchase order
2 Because we did not prepare the purchase order on time.
not prepared on time?
Why didn’t get the signatures
3 Because we did not get all approval signatures on time.
on time?
4 Because we prepared the PO 3 days before the event. Why did we prepare it late?
 5 Because we forgot to prepare a Purchase Order. Why did we forget about it?
Root Because we didn’t have a checklist to clearly identify
Cause: the tasks we needed to complete at what time.

In this case, the root cause is that we lacked a checklist to ensure everything was prepared at the designated
time. The solution is to prepare it.

Will there always be only one root cause?

The example above provides a simplified solution model. When performing 5-why analysis, multiple causes will
emerge from each causation branch. As a result, there will likely be several root causes identified and they
must be prioritized, so you solve the most severe and pressing root cause.

In the next articles on 5-why, several analysis models will be introduced.

Why FIVE why?

In the Toyota method, asking why five times is believed to lead to the conclusion. In reality, the number of times
you ask why will depend on the depth of the problem. Sometimes three or four “why’s” is sufficient to reach the
root cause. With a more complex problem, we can go up to seven or eight “why’s”.

Of course, if there are too few “why’s” then it would indicate that the problem hasn’t been analysed in enough
depth and detail. Too many “why’s” could alternatively indicate over-analysis, and that you’ve lost sight of the
big picture.

Who should perform 5-why?

5-whys must only be done by those who have done a specific job or project, as they have firsthand knowledge
and experience to do so.

For example, imagine that a bank teller just mistakenly transferred money into the wrong account. Luckily, the
problem was reversed before any damage was done.

To find out the root causes of the problem, only the teller is qualified to perform the analysis because she was
the one who experienced it and knew the seen and unseen parts of the problem. Anyone else can only
speculate on why it happened, but the truth can be told only by those who did it.

Weaknesses of 5-why
More information: 5-Why Weaknesses

5-why is based on personal opinion on what the causes are, and two people performing 5-why analysis on the
same problem can come up with widely differing causes and completely different root causes.

The issue is slightly negated as long as the person involved in the problem performs the analysis. If they do,
then they should have enough expertise to perform an accurate analysis.

Summary

1. Identify the problem, then ask “why did this happen” to find causes. Ask “why did this happen” to the causes,
and repeat until we’ve done it five times.
2. Finding root causes allows us to solve the true problem.
3. There are usually more than one root cause.
4. Too few “why’s” may indicate insufficient analysis.
5. Too many “why’s” beyond five-why may indicate over-analysis.
6. Only the person who experienced the problem can do 5-why analysis.
7. 5-why is based on personal opinion and can be flawed, so check your logic.

Read more: An Introduction to 5-why - Karn G. Bulsuk: Full Speed Ahead http://www.bulsuk.com/2009/03/5-
why-finding-root-causes.html#ixzz2rhmZ5XIl
Copyright © Karn G. Bulsuk
Follow us: @karnbulsuk on Twitter | Bulsuk on Facebook

5-whys Analysis using an Excel Spreadsheet Table

TUESDAY, JULY 7, 2009 LEAVE A COMMENT
Find out how to visualize your five-whys analysis by putting it into a spreadsheet,
including a downloadable five why template and tutorial. Part 2 of a four part
series on 5-whys.

By Karn G. Bulsuk

More information: An Introduction to 5-whys, 5-whys Analysis using a Fishbone

Diagram and The Weaknesses of 5-Whys

Downloads: 5-whys Template Download and Step-by-step example on how to

perform a 5-why analysis
Visualizing your 5-whys analysis in a table is the best way to show the causal links
between your causes and the ultimate root causes. One of the easiest ways to do this is
to put it into a spreadsheet - the 5-why Excel spreadsheet template as well as the
example in the article is available for download at the bottom of this article.

Imagine that there is a company called Alencia which specializes in receiving

outsourced executive recruitment work, where they match talent to specific jobs and
receive commission for doing so.

In the past year, demand has boomed and their business has expanded rapidly, but at a
price: while demand has increased, capacity has remained the same, leading to a large
back log of job requests. Previous attempts to bring in a computerized system have
been met with staff resistance and failed. Clients and potential job seekers are both
unhappy with the slow service, and are gradually turning away to more nimble
competitors.

Mio has been put in charge of fixing the current problems, and has been given full
authority to act. To keep things simple, she looked for the root causes using the table
method.

Setting Up the Excel Sheet

In Excel, Mio arranges the table so that it has twelve columns, and set up like in the
illustration below. Each “why” column will contain your why analysis, while each column
in between will consist of arrows leading your reader to the correct Why.

The root cause analysis column will contain all the root causes you identified, while the
recurrence prevention column will contain your recommendations on how to prevent it
from happening again.

To help you save time on setup, a template in Microsoft Office format can be
downloaded at the end of this article.

The First Why

The first why Mio asks comes directly from the stated problem: “Why are processing of
jobs delayed?” From here, she can identify two main causes:

Why Question Answers

Why are processing 1.
of There is no computerized solution to handle job applications.
jobs delayed? 2. There was no formal set of procedures to handle job requests, and
procedures were passed on by mouth as opposed to being documented.

Mio maps those two causes in the “Why 1” column of the spreadsheet.

The Second Why

If there is more than one

answer to a “why” question, they will handled separately when it comes to their turn to
ask why.

Why Question Answers

1. There was staff
Why is there no computerized solution to handle job applications?
resistance
Why was there was no formal set of procedures to handle job requests,
1. There was no system
and why were procedures were passed on by mouth as opposed to being
in place to do so.
documented?

She would then add the answer in the “Why 2” column, with an arrow to link the chain-
of-reasoning together.

The Third Why

This part demonstrates how there can be multiple answers to a Why question, and how
to deal with a branching Why analysis.
Why Question Answers
1. They were not explained the full benefits of the system.
2. They feared being made redundant.
Why was there staff resistance?
3. They were uncomfortable about changing the way they
worked
Why wasn’t there a system in place 1.
to The company grew at an exponential rate that there was
handle job requests? no time to document anything.

To map this out, Mio would add each answer to its own individual cell in “Why 3”. As
you can see, each are legitimate answers to the question, and such branching will help
us to obtain a much deeper and wider 5-why analysis.

The Fourth Why

This set of whys are becoming more involved, but not more difficult as the same basic
principles still apply. She asks “why” to the previous point, and then writes down her
answers in the “Why 4” column.
Why Question Answers
Why were staff not explained the full benefits of the
1. There was a lack of communication.
system?
1. They thought the computer system was
Why did they fear being made redundant?
designed to replace them.
1. They had always been doing it this way.
Why were they uncomfortable about changing the way
2. The positive aspects of the change were
they worked?
not communicated.
Why did the company grow at an exponential rate that
1. There was insufficient planning
there was no time to document anything?

If you notice, the third why which says “they were uncomfortable about changing the
way they worked” branches out into another two whys. Even at this stage, there could
be several answers to the why question.
The Fifth Why

At the final why, you should be focusing on wrapping up your analysis and identifying
the root causes of the problem.

Why Question Answers

Why was there was a lack of
We assumed that the benefits were obvious.
communication?
Why did they think the computer Because we didn't tell them how it would help make
system was designed to replace them? their jobs easier.
Why had they always been doing it this
All the work was done manually prior.
way?
Why were the positive aspects of the
We assumed that the benefits were obvious.
change were not communicated?
Top management were too busy fire fighting and
Why was there was insufficient
dealing with operational work, rather than developing a
planning?
strategy.

Root Causes
At the end of your analysis, you will often come up with a series of common root
causes. In this analysis, Mio has identified the following root causes, and the following
solutions to prevent them from happening again:

Main Root Cause Identified Recurrence Prevention

Insufficient communication in the following Develop a communication strategy to clearly
areas: - Benefits of bringing in a computerized inform staff of the benefits of a software
system. - How the computerized system will assist system to them, and to reassure them that it is
them in their jobs and not make them redundant. not designed to replace their jobs.
Include change management in
No culture of change and sense of insecurity implementation plan. Also, assure staff that
among staff. comprehensive training will be offered in
order to allay fears of change.
Management level: poor work delegation and lack Develop vision, and coordinate resources to
of advanced planning leads management to free up management to engage in strategic
engage in operational level work, and to fire fight planning. Hire more people as necessary, and
instead of focusing on the strategic level. implement a computerized system.

So at the end…

With these findings, Mio is now equipped to develop a strategic plan to solve the current
problems at Alencia.

Downloads

Read more: 5-whys Analysis using an Excel Spreadsheet Table - Karn G. Bulsuk: Full
Speed Ahead http://www.bulsuk.com/2009/07/5-why-analysis-using-
table.html#ixzz2rhnWEMTE
Copyright © Karn G. Bulsuk
Follow us: @karnbulsuk on Twitter | Bulsuk on Facebook
Using a Fishbone (or Ishikawa) Diagram to Perform 5-why
Analysis
SATURDAY, AUGUST 15, 2009 LEAVE A COMMENT
The fishbone (or Ishikawa) diagram is another way to visualize your 5-why analysis, and allows you to
classify your analysis into broad categories. Part 3 of a four-part series on five-why.

By Karn G. Bulsuk

More information: An Introduction to 5-why, 5-why Analysis using a Fishbone Diagram and The
Weaknesses of 5-Why
The fishbone diagram, also known as the Ishikawa diagram, is another tool to provide you with a visual
representation of your 5-why analysis.

The strength of the fish bone diagram is that it allows you to focus on specific cause categories, which may
help you to better focus your line of enquiry. In other words, this diagram is similar to a surgical strike, which
provides more precision. The table method is like the shotgun approach, in which we think of as many possible
causes as possible without a specific path.

In this article, we will be using the same scenario as the table analysis example in the previous article.

An opening tip…
I strongly recommend using paper and pen when you perform the analysis, as it allows you to put your ideas
down much quicker than a computer would. I have found that using a computer to create fishbone diagrams
actually interrupts the flow of ideas, as it requires fiddling around with text boxes and other unnecessary
formatting.

Set up the Fishbone

 Firstly, on a sheet of paper, draw a long line with the box at the end. The line represents the spine of the fish. In
the box, write down the effect. In this case, it is “Application processing was behind schedule.”

Choose your Cause Categories

You can choose to focus your line of inquiry by choosing a set of cause categories: main topics which you will
base your 5-why analysis on. Mio has chosen to focus on methods, management, process and people, since
the problem here is related to these four main areas. She has drawn additional lines from the spine and placed
boxes containing each individual category.

There are also a whole set of common cause categories, some of which are listed below:

• 3M’s and P – Methods, Materials, Machinery, and People

• 4P’s – Policies, Procedures, People and Plant
• 6M’s – Machine, Method, Materials, Measurement, Man and Mother Nature (Environment)
• 8P’s – Price, Promotion, People, Processes, Place / Plant, Policies, Procedures & Product (or Service)
(recommended for administration and service industry)
• 4S’s – Surroundings, Suppliers, Systems, Skills (recommended for service industry)
• Equipment, Process, People, Materials, Environment, and Management

The First Why: Starting your analysis

To figure out why Alencia has so many problems, Mio has decided to first focus on the Methods the company
has employed.

From here, the 5-why analysis is applied as usual, and Mio asks herself “In terms of methods, why was
application processing behind schedule?”

From her observations, Mio understands that a lot of the statistics used in the company are wrong because
many employees are still collecting data and calculating figures using paper and a calculator, before inputting
that data into a spreadsheet. A lot of time is wasted double or even triple checking data because it’s unreliable.

As a result, her answer to the first “why” is: Employees used manual calculations, leading to inaccurate data,
requiring time to find problems and correct them.
 To put it into the fishbone diagram, draw a line
branching off from methods, and write the answer at the end of the line.

The Second Why

Mio wants to understand why people do not use the

full potential of computers. Her next why therefore focuses on this:

Why question: Why did employees use manual calculations?

Answer: They are unable to use complicated Excel formulas.

A line would branch off from the first why line, and the answer would be written at the end.

The Third Why

Why question: Why were they unable to use

complicated Excel formulas?
Answer: Because they lacked Excel training.

The Fourth Why

Why question: Why did they lack Excel training?

 Answer: Management assumed that everyone was able to use Excel to its fullest ability, and did not anticipate
that there would be a lack of Excel skill.

The Fifth Why

Why question: Why did management not anticipate the lack of skill?
Answer: There was insufficient thought put into long-term planning.

Repeat, Repeat, Repeat

Do the same for each “why” you can come up with,

and repeat with each cause category until you complete your diagram.

Cleaning up the diagram

Fishbone diagrams were designed to be done quickly the first time round to ensure the ideas flow smoothly,
and so you should clean it up prior to using it for analysis.

Consider the following:

• Many branches under one category may need further study
• Few branches under one category may need more analysis
• If several major categories have only a few branches, they may need to be combined

Using the Diagram to Find the Root Causes

After Mio has finished filling out the diagram, she now can use it to identify root causes. To do so, she needs to
identify repetitive root causes that seem to appear over and over again by circling ones which keep appearing.
She notices that a lack of training and a lack of marketing on the benefits of a software solution are two root
causes that keep appearing.

Mio’s Conclusion
In her report, Mio concludes that:

“A lack of awareness of the advantages of a software solution and buy-in, coupled with insufficient training on
existing software solutions are two of the leading and fixable root causes.”
Another tip

In the event that your diagram becomes unwieldy and

has so many branches in one cause category, you can split that cause into its own fishbone diagram. In the
following example, Mio split the “people” cause category into its own set.

Read more: Using a Fishbone (or Ishikawa) Diagram to Perform 5-why Analysis - Karn G. Bulsuk: Full Speed
Ahead http://www.bulsuk.com/2009/08/using-fishbone-diagram-to-perform-5-why.html#ixzz2rhmuLOpW
Copyright © Karn G. Bulsuk
Follow us: @karnbulsuk on Twitter | Bulsuk on Facebook

5-Why Weaknesses
MONDAY, SEPTEMBER 7, 2009 LEAVE A COMMENT
As with all tools, 5-why analysis has its share of weaknesses. Find out more
about its limitations, and how to maximize the potential from 5-why. The final part
in a four-part series on 5-why.

By Karn G. Bulsuk
More information: An Introduction to 5-why, 5-why Analysis using a Fishbone
Diagram and 5-why Analysis using an Excel Spreadsheet Table
5-why analysis isn’t perfect. In fact, it’s known to have produced very strange, skewed
and biased conclusions, depending on how it’s used.

One of the major problems is that conclusions reached from 5-why could have widely
different root causes, depending on the analyst’s point of view and experience. Those
who are biased can skew the results even more by producing an analysis in their
favour, while disregarding the other facts present.

Some people may not take the analysis far enough. There are many cases where we
have to ask “why” more than five times in order to find out the true root cause,
especially in complex and convoluted problems.

The final problem to befall the 5-why analysis is human in nature: since 5-why is
qualitative, the conclusion is obviously subjective and open to interpretation.

In smaller, low-stake projects, the flaws tend to be minimized because the temptation to
skew results is lower. Conversely, high-risk projects increase the possibility that 5-why
analysis will be biased and incorrect.

Despite its shortcomings, there are ways to minimize its flaws, so you can minimize the
risk of a faulty root cause while still cultivating the power of this tool.

Group Work
To minimize the risk of a biased conclusion, it would be wise to form a group consisting
of subject-matter experts and those involved in the actual issue. By mixing both, it
ensures that those involved are able to provide first hand accounts of the situation.
Subject-matter experts help to minimize the risk of a one-sided assessment, while still
having the knowledge to make a fair analysis.

Each individual needs to make their own fishbone diagram first, and come up with their
own conclusions and rationale on what the root causes are. The group will then
reconvene and each individual will be given the opportunity to present their findings and
supporting reasons.

Once each individual has done so, a vigorous group discussion will help to prioritize the
fixable root causes.

Split into its Components

In more complex problems, we may need to split the problem into smaller components
to help to focus on the main issues. To do so, you can use one of the major cause
categories you learned about in the fishbone diagram analysis.

But at the end…

5- why analysis is still an indispensible tool for your root cause analysis. With some
foresight, you can overcome some of its weaknesses to come up with solutions which
truly tackle the root-cause of a problem.

You can read more about horenso (effective communication), PDCA (Plan-Do-Check-
Act), mieruka (use of visuals) and 5-why here, which also includes articles, tutorials and
downloadable diagrams, sheets, PDFs and other tools to help you implement kaizen
and bring the competitive edge of the Toyota Way to your manufacturing or service-
industry project or organization.

Read more: 5-Why Weaknesses - Karn G. Bulsuk: Full Speed

Ahead http://www.bulsuk.com/2009/09/5-why-weaknesses.html#ixzz2rhnmwAQv
Copyright © Karn G. Bulsuk
Follow us: @karnbulsuk on Twitter | Bulsuk on Facebook

The Five Whys Analysis FAQ

SATURDAY, FEBRUARY 11, 2012 LEAVE A COMMENT
There are some very common questions about the five why analysis. Here are some of the most
frequently asked ones.

By Karn G. Bulsuk
The five whys are just one way of finding the root cause of a problem, but arguably one of the most well-known
methods. For such a popular methodology, it has gained its fair share of questions on its usage: of which some
of the most popular and frequently asked are answered here.

Why only 5-whys? Why can't I ask why more than five
times to achieve, six, even or even eight whys?
There's nothing stopping you from going beyond five-whys. There are some cases where you should if you still
haven't logically reached the root cause by the time you get to five. It's more likely though, that if you're going
over five-whys, it's likely that the line of inquiry is becoming too detailed and unlikely to reach the root cause.

Going over five whys for your root cause analysis will get tiring and tedious very quickly, especially if you've
branched out into analysing a large number of possible root causes. The reason why five is a good number is
that it forces you into keeping the analysis short and sweet, preventing fatigue without sacrificing quality of
results.

Can I ask "why" fewer than five times?

In most cases, an inability to reach up to five whys indicates that the line of inquiry is not deep enough and the
conclusion unlikely to be the root cause. In such a case, it is best to try to carry on by asking "why" over and
over again. If the cause simply doesn't lend itself to being asked "why", then it may be time to abandon that line
of inquiry.

When I did my 5-whys analysis, I came up with a

number of "stupid" root causes. Should I also use
that?
The 5-whys don't require that you leave your common sense at the door. If some of the root causes simply
don't make sense, you can always pick some of the other root causes that do make sense.

Is there a way to visualise the five whys, so I can see

what I'm analysing?
You can use an Excel spreadsheet to perform five whys analysis. The strength of this technique is that you
have the tools ready on your computer, and since you can add more columns easily, you can branch out your
analysis as much as necessary.

You can also what is known as a fishbone diagram, which is also known as an Ishikawa diagram. This
technique is more suitable for those who prefer paper-and-pen. The strength of this technique is that it helps
you to classify your causes into broad categories, focusing your analysis.

* * *

More questions? Ask away in the comments below!

Read more: The Five Whys Analysis FAQ - Karn G. Bulsuk: Full Speed
Ahead http://www.bulsuk.com/2012/02/five-whys-analysis-faq.html#ixzz2rhnySCqQ
Copyright © Karn G. Bulsuk
Follow us: @karnbulsuk on Twitter | Bulsuk on Facebook!
!
!

5-Whys Guide& Template

!!
The 5-Whys is a simple brainstorming tool that can help QI teams identify the root cause(s) of a problem. Once a general
problem has been recognized (either using the Fishbone Diagram or Process Mapping), ask “why” questions to drill down
to the root causes. Asking the 5-Whys allows teams to move beyond obvious answers and reflect on less obvious
explanations or causes.
!
Step-by-step instructions
!!
1. State the problem you have identified as a strategic problem to work on.
!
2. Start asking “why” related to the problem. Like an
inquisitive toddler, keep asking why in response to
each suggested cause.
3. Ask as many whys as you need in
order to get insight at a level that can be addressed
(asking five times is typical). You will know you have
reached your final „why‟ because it does not make
logical sense to ask why again.
!
The 5-Whys is a strategy that is often used after
an issue has been identified using another tool,
such as a Fishbone Diagram or Process
Mapping. Guard against using the 5-Whys
questions on their own to avoid a narrow focus or
bias.!
!
It is said that only by asking "Why?" five times
!
successively, can you delve into a problem deeply
enough to understand the ultimate root cause. By the time you get to the 4th or 5th why, you will likely be looking squarely
at management practices (more than five whys may be required for complex problems).
!!
This methodology is closely related to the Cause & Effect (Fishbone) diagram, and can be used to complement the
analysis necessary to complete a Cause & Effect diagram.! !

5) Why? that‟s our standard policy

!!
At this point you understand the root cause, and can see where a change is needed.

5-Why Analysis Template

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