3L and 5 Why Presentation - MKG

The 5-Whys: A Simple
Effective Problem-Solving Tool

How many of you deal with
problems that need solutions
as part of your job function?
The Truth about Problems….
 “No one has more trouble than the person who
claims to have no trouble.” (Having no problems is
the biggest problem of all.)
-Taiichi Ohno, father of the Toyota Production System
 At Toyota:
 A problem is defined as the gap between the current
situation and the ideal situation
 The 5-Why analysis is the primary tool used to determine
the root cause of any problem. It is documented in the
Toyota Business Process manual, and practiced by all
associates
5 Why Training Objective
Objective: To provide a simple and effective problem-solving
methodology that will result in identifying the "True Root Cause" and
appropriate Corrective Actions for significant quality issues.
When to Use 5 Why:
 The problem and root cause is not immediately apparent

 Prevent a problem from occurring in the future
 Analyzing a formal customer complaint
 Departmental metric – KPI - is RED
Resolve an internal audit finding
When the problem is a “repeat issue” – Delamination/Runout
What 5 Why Is NOT
5 Why analysis is NOT:
A difficult process
A way to find root cause without

conducting a proper investigation
A list
of five perfect questions, all of
which begin with "WHY"
An absolute number of questions
A reporting tool to be filled in after

you’ve figured out root cause
Deduction
Opinion
Folklore (traditional beliefs, customs,).
What Is It?
5 Why is a structured approach in which you repeatedly ask WHY? to understand the
underlying causes of the issue, AND to generate an effective corrective action to mitigate
the incident, and prevent future occurrences. It is a widely used tool used by
Lean and Six Sigma leaders
5 Why analysis is used to identify and /or to document the
cause/effect relationships associated with a problem/error and its root cause
5 Why analysis is based on “hands on” observation/investigation, ,

– “Understand the process”
– “Talk to the appropriate member or staff personnel”
– “Without data, you are just another person with an opinion”
Get to the true

Root Cause
Don’t just “Fix it and

forget it”
5 Why – Your first introduction?
Remember when you were 5 years old or your 5 year old
son or daughter asked you the question WHY?
Every answer triggered another “why?”

Remember when you were 5 years old or your 5 year old
son or daughter asked you the question WHY?
– Why do leaves change colors?

Remember back to when you were 5 years old or your 5
year old asked you the question WHY?

» They stopped making chlorophyll, which is green.

– Why did they stop making chlorophyll?

» There isn’t as much sunlight in the winter and trees need sunlight to
make chlorophyll.

make chlorophyll.
– Why isn’t there as much sunlight in the winter?

make chlorophyll.
» The days are shorter and sunlight isn’t directly overhead.

make chlorophyll.
– Why are the days shorter and the sunlight not as directly overhead?
»

make chlorophyll.
» The earth rotates on an axis that isn’t straight up and down.

make chlorophyll.
– Why isn’t the earth’s axis straight up and down?

make chlorophyll.
– Why isn’t the earth’s axis straight up and down?
» Hey, I’ve got an idea! Would you like
me to get you some ice cream?
Problem Statement :
Bird Droppings On The Jefferson Memorial
• Why?
Problem Statement :
• Why? – Lots of birds were perching on the roof
• Why?
Problem Statement :
• Why? – They came for the food – lots of spiders
• Why?
Problem Statement :
• Why? – Spiders came to eat the moths
• Why?
Problem Statement :
• Why? – Large number of moths accumulate at the
Memorial during the early evening (at dusk)
• Why?
Problem Statement :
• Why? – Large number of moths accumulate at the
Memorial during the early evening (at dusk)
• Why? – Moth’s are attracted to light.
The flood lights for the Memorial were programmed to be
turned on 30 minutes earlier than any other monument.
(ROOT CAUSE)
Solution – Turn all monument lights on at the same time to
reduce moth’s initial attraction to this monument.
Problem Solving 5 Why Funnel
Systemic CorrectAction
1. Clearly state the
problem.
2. Write it down on a
flip chart.
3. If there are multiple
problems, write each
of them down, and
address separately,
but choose the most
critical.
1. Gather a diverse
team.
2. Gather information.
3. Review the process
itself and all related
documentation.
4. Educate yourself and
the team.
1. Determine the first

Why?
2. Discuss and review
with the team.
3. Ask if you are looking
at the problem from
all aspects.
4. Avoid assumptions!
1. Repeat the process

for the remaining
Whys?
2. Keep probing until
you come to an
answer that you can
control.
1. Agree to root cause.

2. Define the short-term
and long-term
corrective action.
3. Investigate the
“Systemic Issue”.
1. Investigate the
“Systemic Issue”.
2. These three boxes
represent the 3 legs
of a 3-legged 5 Why
analysis
When to Use 5 Why
5 Why Analysis can be used with various

problem solving formats
Internal Problem Solving

GM Drill Deep
Ford 8 D (Discipline)
Chrysler 8 Step
5 Why, when combined with other

problem solving methods, is a very
effective tool
Problem Definition
Define the problem

Problem statement clear and accurate
Problem defined as the customer sees it
Do not add “causes” into the problem statement
Examples:
GOOD: Customer received a part with a broken mounting pad
NOT: Customer received a part that was broken due to improper
machining
GOOD: Customer received a part that was leaking
NOT: Customer received a part that was leaking due to a missing
seal
Specific Problem
Why did we have the specific non-conformance?

How was the non-conformance created?
Root cause is typically related to design,

operations, dimensional issues, etc.
Tooling wear/breaking
Set-up incorrect
Processing parameters incorrect
Part design issue
Typically traceable to/or controllable by the

people doing the work
SPECIFIC PROBLEM
Root Cause Examples

• Parts damaged by shipping – dropped or stacked incorrectly
• Operator error – poorly trained or did not use proper tools
• Changeover occurred – wrong parts used
• Operator error – performed job in wrong sequence
• Processing parameters changed
• Excessive tool wear/breakage
• Machine fault – machine stopped mid-cycle
Specific Problem
What if root cause is?
Operator did not

follow
instructions
Do we stop here?
Specific Problem
Operator did
not follow
instructions
Do standard
Create a
work
standard
instructions
instruction
exist?
Or do we
Is the operator
attempt to trained?
Train operator
find the root Create a

Were work system to
cause? instructions assure
correctly conformity to
followed? instructions
Are work Modify

instructions instructions &
effective? check
effectiveness
Do you have the

right person for
this job/task?
Specific Problem
Specific Problem
Column would not lock
in tilt position 2 and 4
Tilt shoe responsible for

positions 2 and 4 would not
engage pin
Shifter assembly screw lodged
below shoe preventing full
travel
THEREFORE
Screw fell off gun while
pallet was indexing
WHY??
Magnet on the screw bit
was weak
Exceeded the bits workable life

Specific Problem
Specific Problem
Loss of torque at rack inner tie
rod joint
Undersized chamfer (thread

length on rack)
Part shifted axially during

drill sequence THEREFORE
Insufficient radial clamping
load. Machining forces
WHY?? overcame clamp force
Air supply not maintained
Various leaks, high demand at full

plant capacity, bleeder hole plugs
caused pressure drop
Detection:
Why did the problem reach the customer?

Why did we not detect the problem?
How did the controls fail?
Root Cause typically related to the inspection system

Error-proofing not effective
No inspection/quality gate
Measurement system issues
Typically traceable to/or controllable by the people doing the

work
Detection
Example Root Causes
• No detection process in place
• Defect occurs during shipping
• Detection method failed – sample size and frequency
inadequate
• Error proofing not working or bypassed
• Gage not calibrated
Detection
Detection
in tilt position 2 and 4
On-line test for tilt function is not

designed to catch this type of defect
THEREFORE
Test for tilt function is applied
before shifter assembly
Process flow designed in

this manner – would not
detect shifter assy screw
WHY?? lodged below tilt shoe
Detection
Detection
Loss of torque at rack

inner tie rod joint
Undersized chamfer/thread length

undetected
THEREFORE
Inspection frequency is
inadequate. Chamfer gage
is not robust
WHY??
Process CPK results did not reflect
special causes of variation affecting
chamfer.
Systemic
Why did our system allow it to occur?
What was the breakdown or weakness?
Why did the possibility exist for this to occur?
Root Cause typically related to management
system issues or quality system failures
Rework/repair not considered in process design
Lack of effective Preventive Maintenance system
Ineffective Advanced Product Quality Planning (FMEA, Control Plans)
Typically traceable to/controllable by Support

People
Management
Purchasing
Engineering
Policies/Procedures
Systemic
Helpful hint: The root cause of the
specific problem leg is typically a good
place to start the systemic leg.
Root Cause Examples
• Failure mode not on PFMEA – believed failure mode had
zero potential for occurrence
• New process not properly evaluated
• Process changed creating a new failure cause
• PFMEAs generic- not specific to the process
• Severity of defect not understood by team
• Occurrence ranking based on external failures only, not
actual defects
Systemic
Systemic
in tilt position 2 and 4 Root Cause
Detection for tilt function done

prior to installation of shifter
assembly
THEREFORE
PFMEA did not identify a
dropped part interfering with
tilt function
WHY?? First time occurrence for this

failure mode
Systemic
Systemic Root Cause
rod joint
Ineffective control plan related to

process parameter control (chamfer)
THEREFORE
Low severity for chamfer control
Dimension was not

WHY?? considered an important
characteristic – additional
controls not required
Insufficient evaluation of
machining process and
related severity levels
during APQP process
Specific Problem
•Corrective Action:
•Reset alarm limits to sound if <90 PSI.
•Smith 1/12/17
rod joint •Disable machine if <90 PSI.
•Jones 12/28/16
•Dropped feed on drill cycle to .0058
Undersized chamfer (thread from .008.
length on rack) •Davis 1/10/17
•Clean collets on Kennefec @ PM
frequency
Part shifted axially during
drill sequence •Smith 1/12/17
•Added dedicated accumulator (air) for
system or compressor for each
Insufficient radial clamping Kennefec
load. Machining forces •Smith 1/12/17
WHY?? overcame clamp force •Verify system pressure at machines at
beginning , middle, and end of shift
Air supply not maintained •Smith 1/12/17
Various leaks, high demand at full

plant capacity, bleeder hole plugs
caused pressure drop
Detection
Corrective Action:
•Implement 100% sort for chamfer length and
Loss of torque at rack thread depth.
inner tie rod joint
•Smith 12/26/17
•Create & maintain inspection sheet log to validate
Undersized chamfer/thread length
•Davis 11/22/17
undetected
•Redesign chamfer gage to make more effective
•Jones 2/30/17
Inspection frequency is
inadequate. Chamfer gage •Increase inspection frequency at machine from 2X
per shift to 2X per hour
is not robust
•Johnson 1/14/17
•Review audit sheets to record data from both ends
Process CPK results did not on an hourly basis
reflect special causes of
•Davis 1/4/17
variation affecting chamfer.
•Conduct machine capability studies on thread
depth
•Jones 12/22/17
•Perform capability studies on chamfer diameters
•1/14/17
WHY?? •Repair/replace auto thread checking unit to
include thread length.
•1/18/17
SYSTEMIC
Loss of torque at rack
inner tie rod joint Corrective Action:
•Design record, FMEA, and Control Plan to be
reviewed/upgraded by Quality, Manufacturing Engineering
Ineffective control plan
related to process parameter •Update control plan to reflect 100% inspection of feature
control (chamfer)
•PM machine controls all utility/power/pressure
•Implement layered audit schedule by Management for
Low severity for chamfer robustness/compliance to standardized work
control
Lessons Learned:
Dimension was not •PFMEA severity should focus on affect to subsequent internal
considered an important process (immediate customer) as well as final customer
characteristic – additional •Measurement system and gage design standard should be
controls not required robust and supported by R & R studies
Insufficient evaluation of •Evaluate the affect of utility interruptions to all machine

machining process and processed (air/electric/gas)
related severity levels
during APQP process
WHY??
In order to clarify the root cause,
thoroughly investigate the process involved
Problem to Pursue “WHY?” (Speculate Causes)
Confirm facts, and if there’s no

Cause Cause cause-and-result sequence in the
cause, stop asking “WHY?”
Don’t expand the tree until
the data suggests that it be
expanded Cause
Repeatedly ask “Why?” Cause
If an item is not a Root Cause, Root Cause

do not focus on
Countermeasures or corrective Countermeasure
actions
NASA Fishbone Diagram
Validate your Root Cause….
1. Can you recreate the Problem, or

turn it “ON” and “OFF”?
2. Are the problem and root cause
clearly connected?
Use the “Therefore” test as a check
Root Cause Analysis:
Prioritized Problem: therefore
why therefore
why therefore
why therefore
why therefore
why therefore
why Root Cause
“Therefore” logic fails if the analysis:

1) Skips a step
2) Jumps to a conclusion
3) Tries to fix a “known issue” into the flow
Therefore Test - Applied
To test the logic start with the root cause and work backwards to the
Problem statement: WATER IS COMING THROUGH A HOLE IN THE WALL

1. There’s a hole in the water pipe.


2. Because a nail has been hammered through the pipe

3. Because the renovator was not aware of the pipes position

4. Because the renovator had not examined a drawing showing the pipes position

5. Because this is not part of the renovator’s standard work to examine a drawing

START at the Bottom of your 5-Why and apply the “THEREFORE TEST”

5. It is not part of the renovator’s standard work to examine the drawing



4. Therefore the renovator had not examined the drawing showing the pipes position


3. Therefore the renovator was not aware of the pipes position


2. Therefore a nail has been hammered through the pipe


2. Therefore a nail has been hammered through the pipe
1. Therefore there is a hole in the water pipe
THEREFORE - WATER IS COMING THROUGH A HOLE IN THE WALL

5 Whys – Points to Remember
Processes Learning Points
1. Clearly define the
problem. Consider 1. Do not assume anything…
causes without
prejudices 2. Thoroughly investigate the process
and clarify the work flow; was the
2. Based on facts gathered
process followed?
during the investigation,
keep asking “Why?” 3. Follow the data to determine the root
cause based on “facts”
4.Check if one more “Why?” is needed,
3. Specify the root cause(s) be logical: don’t over or under analyze
…the final number may not be 5
Root cause does not point to an individual

Focus on the process not a person
3 Legged 5 Why
Investigate the causes of each leg of the 3 Legged 5 Why
Leg 1) Why did the defect/issue occur, or why did we have the problem?
Leg 2) Why did our detection system fail to protect the customer from
receiving the defect/issue or fail to detect the error internally?
Leg 3) Why did our business system fail to prevent the error?
 Should be completed in the sequence listed
 Each leg may require different teams, or different expertise
Shift from “fire
- Leg 1 fighting” to
“problem solving”
- Leg 2
- Leg 3 - Error
- Detection
- Prevention
3 Legged 5 Why Overview
5 Why Guidelines
Problem Definition
–Ensure the analysis is based on the problem as the Customer sees it
–Thoroughly familiarize yourself and your team with the current process
prior to completing the 5 Why analysis
3 Legs
–Does the evidence and documentation support the validity of the cause and
effect relationship? Don’t base your analysis on folklore or opinions!
– Are the causes easily understood?
–Is there a true cause-and-effect path from beginning to end of each path?
–Does the path make sense when read in reverse from cause to cause?
(e.g., We did this, “Therefore” that happened)
Corrective Action
–Does the evidence support the validity of the corrective actions?
–Does each corrective action address the root cause from every path?
» Did you consider more than one corrective action for each root cause?
– Are the corrective actions irreversible?
5 Why’s – Final Thoughts
How could this problem/error have been foreseen? Or how could we have
protected the customer? Do we have the right controls in place?
How will this information be incorporated into our systems?
Are there lessons learned that could impact the Customer? How can these
lessons learned be communicated and investigated in
other areas (Look Across)?
5 Why analysis can be used to demonstrate and clarify the linkage

from the top-level problem down to the underlying root cause.
Using the 3 Legged 5 Why to understand the poor detection as well as

systemic issues that allowed this event and similar events to occur.
Management is usually in the best position to know whether an event

may be another example of a systemic problem.
During the 5 Why analysis, you should ask if there are similar situations that need to
be evaluated … Perform a “Look Across” the organization. If this situation could
apply to multiple facilities, then the corrective action must address all fa c i l i t i e s .
Root Cause – Reflection Points
Ask , “Will implementing the Systemic Corrective Action prevent the next
failure?” If the answer is “NO”, you must understand the deeper WHY.
If human error is identified, understand why the human committed the error.
• What management controlled factor impacted performance?
• What system must change to eliminate (or significantly reduce) the chance for
error?
“Training the Operator” should never be used as an excuse!

• Why was the operator not trained properly?
• Why was the training not effective?
• What environmental factors caused the operator to not do his/her best work?
• Did he/she have to go around the system due to other issues or pressures?
• Can the system be error-proofed?
LESSONS-LEARNED
For virtually every incident, some improvement(s) in the Management Systems could
have prevented most (or all) of the contributing events --- ASQ estimates 82-86%

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The 5-Whys: A Simple

Effective Problem-Solving Tool

When to Use 5 Why:

 The problem and root cause is not immediately apparent

A way to find root cause without

A reporting tool to be filled in after

5 Why analysis is based on “hands on” observation/investigation, ,

Get to the true

Don’t just “Fix it and

Every answer triggered another “why?”

Every answer triggered another “why?”

– Why do leaves change colors?

Every answer triggered another “why?”

– Why do leaves change colors?

Every answer triggered another “why?”

– Why do leaves change colors?

Every answer triggered another “why?”

– Why do leaves change colors?

Every answer triggered another “why?”

– Why do leaves change colors?

Every answer triggered another “why?”

– Why do leaves change colors?

Every answer triggered another “why?”

– Why do leaves change colors?

Every answer triggered another “why?”

– Why do leaves change colors?

Every answer triggered another “why?”

– Why do leaves change colors?

Every answer triggered another “why?”

– Why do leaves change colors?

1. Determine the first

1. Repeat the process

1. Agree to root cause.

5 Why Analysis can be used with various

Internal Problem Solving

5 Why, when combined with other

Define the problem

Why did we have the specific non-conformance?

Root cause is typically related to design,

Typically traceable to/or controllable by the

Root Cause Examples

What if root cause is?

Operator did not

find the root Create a

Are work Modify

Do you have the

Tilt shoe responsible for

Exceeded the bits workable life

Undersized chamfer (thread

Part shifted axially during

Air supply not maintained

Various leaks, high demand at full

Why did the problem reach the customer?

Root Cause typically related to the inspection system

Typically traceable to/or controllable by the people doing the

On-line test for tilt function is not

Process flow designed in

Loss of torque at rack

Undersized chamfer/thread length

Typically traceable to/controllable by Support

Detection for tilt function done

WHY?? First time occurrence for this

Ineffective control plan related to