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 "6" 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.Eee) Customer! Internal / Supplier Issues from QSYS & Other sources, Team Detect description (5) Containment ation (8) Root Cause (6) ig Cree permanent comectve acon (3) Fg) Comectve action effectiveness contol Long tem action to prevent reoccurrence Team and ldividual Recognition ‘The ZF problem solving process begins with the 8D, This documents the actions beginning with team identification and ending with team recognition once the problem has been eliminated. What happens in between D1 and D8, can vary greatly depending on who is managing and/or solving the particular problem, Many different strategies and tools may be employed. The 8D can be used on any type of problem, both technical and non-technical.Eee euca) Team Defect descpton(s) DI) conarmentacion TE Root cause sy GE) Chosen permanent corrective action (s) Tonecive achon effecivensss conkol Long tem action to prevent reoccurrence: [ [lazy Team and individual Recagniion | ‘The standard problem solving root cause documentation is the 3x5 Why. This documents the link between the problem statement and the root causes of: + Why Made + Why Shipped + Why Not Predicted in APQP process. It does not define the tools or methods for diagnosing the root cause,ee oo Doe ose (6) HEEB contcoment action(s) a0 Chosen permanent corrective action (s) Tg) Lone term acton to provontreoceurrones Problem Solving Statogios, Tactes ‘and Tools a8 propriate to specific problem [Mee To ae ra Racoon 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 aid the problem occur? Cause Leg Why was faiuro mode created? Specific Root Cause Detection Root Why were existing controls not sufficient to catch the problem Cause Leg Hctent it escaped? Systemic Root why did our Quality systemsnot Cause Leg protect the customer? May require more or fewer than 5 Why’sThe Three Legs Manufacturing System What CA will be implemented to prevent the failure mode from being created Prevent” Corrective Action Quality System What CA will be implemented to Insure that i the fatlure mode is created, it will be detected before it leaves the plant “protect” Corrective Action APQP System ‘What CA is required in the QMS ta ensure the Specific and Detection Failure modes will not happen in the future “Predict” Corrective ActionThe three legs If we get these root causes wrong then the corrective actions will not address the proper “prevent”, protect” ‘and “predict” causes. We may miss one. “Protect” Corrective Action emic” “Predict” Corrective WHY? Root cause ‘ationPitfalls Potential Pitfalls -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.Who to Involve Floor level -Production Skilled Trades “Material Control 1 Line Supervisor Specific Root Cause Detection Root Cause People doing the How was the problem work created? How did the problem escape? Support ~ “Management Systemic Root Cause Purchasing Why weren't our and Quality Management Systems robust enough -Engineering to adequately predict the failure and protect the customer? -Procedures and policies People who set up the processesStructuring a “5 Why” "What. is wrong with s/t?" Problem Statement [Object ] [Defect Bill was late ; a” T for work The front right rotor is eracked, Why? The steering gear leaked. Bill is late for work. Bill's car Therefore didn’t start £ The battery Therefore cI meee Lo Car door was left Therefore ajar Why? Dome light was on all night Why? Root CauseZF 3 x 5 Why Template (QSYS) —_ ——— 1 Corrective These are tied = Lk Actions ‘directly to root of ‘causes Identified in each leg. IF we get the root ‘cause wrong for each leg, the CA will be wrong.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 § 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"? Unt Leaking iy did customer experience the problem? - wil “Vehicle set Fault Code Part Fallure mode typical be one or tno Wy from customer Spump = Nowy Se created inthe problem, Usually ths wil be te fle made in the ~ plant. Product. ~ “Fastener not tightened: "ep n bore Specific Cause Leg Lot of spec. “threads oversued “Missed operation ‘What in the process happened to create the “specific” YF failure mode. hip into ld (the Faure ‘mode is bore too large) Read the leg backwards, but stating "therfore” instead of asking WHY? Therefore] + contamination on seal (if Problem ts leak) Each step back must make sense with the statement “Machined part reloaded to “therfore”. ‘machining center (faire mode - - ‘savers. thread).Logic of the 3 legs ‘The Failure mode becomes the frst Dox of tsatedin the detection leg, Weneed to theplant _) understand why once the fare mode ‘was created, why it was not detected Detection Cause Leg, rota otc pac tr “Detection” ph icteric Root Cause +-Gage out of calibration -Pat bypassed npetn due fo,non-standard work.Logic of the 3 legs We can go a step deeping into Detection. We addressed why the failure made was not detected. ‘We can also ask why the Specific Root Cause was not detected. In other words, why did we not detect the condition or event that allowed the failure mode to be created,Logic of the 3 legs ‘The Systemic Cause Leg will typically begin with either the ‘specific or Detection Root causes and in most cases itis ‘appropriate to include legs for beth. Two Systemic Root ‘Cause Lags can be shown, Systemic Cause Leg Operator traning matrix vas rot reviewed pric to assigning operator to cal. =specific root cause was not included in PFMEA when ‘addtional machine added to cal.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 Is this a Good or Bad “Specific Cause” Leg? Review and determine if: 1. Any of the Why's could be answered differently? Does this end at the root cause? Are Systemic or detection causes included? 4, Any other errors in path? 2. 3. Threads out of spec. due to Why going through Process mapping tapping op. twice | | and material flow is confusing to ‘Addition of relief new operators operators with inadequate experience resulted in parts going through tapping twiceIs this a Good or Bad “Specific Cause” Leg? Should be broken out into two Bracket joint Why separate Why's. Remember, don't lump too much felled to meet information together or skip steps in logic. Threads stripped Why ‘Threads out of spec. due to going through Process mapping tapping op. twice} | and material flow is confusing to ‘Addition of relief new operators operators with inadequate experience resulted in parts going through tapping twiceIs this a Good or Bad “Specific Cause” Leg? Why Fastener joint failed to meet Operator place treve These are systemic previously problems, not what tapped parts into actually happened to tapping station create the failure This Is the action that “caused” the ae parts to be out of spec, due to going through Procéss mapping tapping op. twice | | and material flow is confusing to Addition of relief new operators operators with inadequate experience, resulted in parts going through tapping twiceIs this a Good or Bad “Speci ic Cause” Leg? A corrective action on the “specific” root cause will prevent parts from being placed into tapping operation twice. Operator place previously tapped parts into tapping stationIs this a Good or Bad “Detection Cause” Leg? Why Review and determine if : 1. Any of the Why's could be answered differentiy? Does this end at the root cause? Any other errors in path? 2. Existing process 3. controls did not prevent operator 4 from placing parts into tapping twice Machining center did not have controls to detect previous tapped partIs this a Good or Bad “Detection Cause” Leg? Why Threads out Machining center did not have controls to This is the detection leg, detect previous but we find the word Therefore [tapped part preventIs this a Good or Bad “Detection Cause” Leg? Why Therefore Machining center did not have controls to detect previous tapped partIs this a Good or Bad “Detection Cause” Leg? Why Machining center did not have controls to detect previous tapped part Parts are not measured 100% after tapping to verify dimensions Corrective action #1 would address detection of previously tapped parts being placed into machining center. Correction action #2 would address detecting a part that has been tapped twice from being shipped to customer or next operationIs this a Good or Bad “Systemic Cause” Leg? Review and determine if : 1. Any of the Why's could be answered differently? 2. Does this end at the root cause? 3. Any other errors in path? ‘APQP/FMEA did not consider double tapping a risk No prior customer returns for 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 fallure mode = APQP/FMEA did exists. We need to consider our Specific root not consider POP system, and how we cause double tapping a determine and evaluate risk( considered but isk RFMEA, lessons leamed, read not detection —Theref across, ..) Machining center did not have controls to detect What corrective action will be considered for systemic root cause related to specific root cause?......Process standards, etc, What corrective action will be RFMEA required for all equipment. considered for systemic root cause related to detection? previous tapped partExamples of Systemic Root Causes ‘system root causes may be considered those things we must update in procedures, documentation, APOP, 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 fallure to happen. How will we ensure ‘we don't miss It again? ™ Process steps not robust or followed: PEMEA Process Flow Diagram Control Plan ‘Changeover process / procedure Preventative / Gage Maintenance Error and Mistake Proofing Reaction Plans / Escalation, ™ Process controls inadequate SPC limits! sample size — Process capability = Operator work instructions Lot traceabilityExamples of Systemic Root Causes @ Quality system non-conformance — Improper changeover — Inadequate contro! of non-conforming product — Failure to act on early warning — Failure to foliow procedures = Change management = Change process not followed = Customer not property informed ~ Documentation not updated prior to implementation (DIPFMEA, 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.