5-WHY RCA

Refresher Clinic

Copyright of Royal Dutch Shell plc 12/19/20 RESTRICTED 1

5-Whys Concept
?
Simple Example - The vehicle will not start. (the problem) 1

Why? - The battery is dead. (first why)

Why? - The alternator is not functioning. (second why)
Why? - The alternator belt has broken. (third why) ?
?
Why? - The alternator belt was well beyond its useful service life and not 5
2
replaced. (fourth why)
Why? - The vehicle was not maintained according to the recommended
service schedule. (fifth why, a root cause)
Why? - Replacement parts are not available because of the extreme age
of the vehicle. (sixth why, optional footnote)

Solution - Start maintaining the vehicle according to the recommended ? ?

4 3
service schedule. (possible 5th Why solution)
- Purchase a different vehicle that is maintainable. (possible 6th
Why solution)
When to Stop -The questioning for this example could be taken further to a
sixth, seventh, or higher level: the "five" in 5 Whys is not magic, but five
iterations of asking why is generally sufficient to get to a root cause.

Premise –
• Avoid assumptions and logic traps
• Instead trace the chain of causality in direct increments from the effect
through any layers of abstraction to a root cause that still has some
connection to the original problem.

Copyright of Royal Dutch Shell plc 12/19/20 RESTRICTED 2

Sample Template Using 5-WHY

Ask The Questions Various Causes to Validate Corrective Actions Applicable

1  
2  
1st WHY 3  
4  
5  
1  
2  
2nd WHY 3  
4  
5  
1  
2  
3rd WHY
3  
4  
1  
4th WHY 2  
3  
1  
5th WHY 2  
3  
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Operational Spill Sample Template Using 5-WHY
Problem Statement: 3” OBIGBO W/3L FLOW LINE LEAK

Further Investigation/ Corrective Actions

Ask the Questions Various Causes to Validate Applicable
Sabotage (no sign of human activity)
*Corrosion – Internal, external Run a wall thickness measurement to confirm
*Mechanical Damage ( heavy vehicular movement in a built up Run 5-Why on this trail
area, pipe 1 m depth with no coating or surface barrier
Run a wall thickness measurement to confirm
*Degradation by Age - Line laid 25 years ago
* FL replacement programme not complied with (end to end) & only Verify why the FL replace was not completed? Is
sectional replacement done (budget constraints??) and FL not the outstanding action captured in FIMS?
captured in FIMS??)
*Mal-operation N/A
1. Why was there a leak? *Pipe installation methodology
2. Why was there Corrosion? *Observed heavy rusting on the exposed pipe section Yes - indicative of external corrosion
*No evidence of coating (laid bare) Complete line replacement and wrap all
outstanding lines.
*the CP is currently functional but the trend of CP reading needs Investigate the efficiency of the CP and trend
confirmation??
*Wall thickness measurement?? Run a wall thickness measurement to confirm
*Fluid Characteristics – Non acidic, LP flow, 38.4% BS&W Acceptable - not indicative of corrosion
enhancement
*Type of hole – Pin? Tear? Sectional Deformation (clamp held, not Excavate and inspect the hole characteristics
considered a likelihood)
3. Why was the line laid bare? *Line originally laid on the surface & buried later due to Investigate the line laying history
urbanisation??

*Construction/Installation did not comply with standard for FL Comply with the DEP requirements for buried
burial, 25 years ago?? lines.

*Line was hooked up to CP system – protection level achieved?? Investigate the efficiency of the CP and trend

4. Why was
Construction/installation
standard not complied with?
5. Why was Inadequate Site
supervision/inspection
(QA/QC)?
* Organisational changes without handover
*Ambiguous Standard/ Communication?? Comply with the DEP requirements for buried
lines.
*Inadequate Site supervision/inspection (QA/QC)?? Investigate the efficiency of the current
supervision strategy of FL contracts
*Contractor cutting corners?? Investigate the efficiency of the current
supervision strategy of FL contracts
*Project timeline/delivery??
*Contract Overload Define and implement the effective number of
contractors per supervisor bearing in mind the
work load and spread
*Use of 3rd party QA/QC inspectors Deploy competent QA/QC inspectors under Shell
Supervisor watch.

Legends
Multiple Shades of Green - 5Why
Trail for one Root Cause Yellow - Further investigation required Blue - Definite preventive action White - Observation/ No further action required
5 WHY Reporting Template
5-why Reporting T em plate
Fa cility/Equipme nt TAG Numbe r
De scribe Fa ilure :

SAP Corrective W ork Order : Criticality

Technician's Name: Date:

Root Cause/5 Why Notes / Comments:

W hy 1
W hy 2
W hy 3
W hy 4
W hy 5
Short Term Actions:
1

To b e com pleteed b y the Supervisor

Proposed Action to Prevent Recurrence:
Options Instruction Re quire d Re fe re nce Numbe r
Do nothing Y/N
Y/N SAP
PMR; SAP PM change Use SAP amendment process notif. no.
Initial Plant Change Raise PIR Y/N PIR. No
Change operational Amend CMS/ ODT /POPM/ SOP Y/N POPM
procedures/ instructions

Details: …………………………… Y/N

Other

Supervisor's Name: Date:

After completion and raising actions, file this form locally.

Note :
POPM - Plant Operating Procedures manual / Operating Manual
ODT - Operations Desktop
SOP - Supplementary Operational Procedure/ temporary Operational Instruction
PIR - Plant Improvement Request