Details about 5 Why tools for root cause identification of any failure of equipment / systems etc

1. 5 Why Analysis5 Why Analysis
Prepared By
Md Aminul Islam
Reliability Engineer
SADAF-SABIC,KSA

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 Where does 5-Why Fit within the PRR process
 Understanding of 5-Why
 Quick 5-Why Exercise as a group
 Critique Sheet
 5- Why Examples
 Wrap Up/Discussion

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 After a supplier has submitted an initial response and containment
plan (Step # 2 in the PRR process), a detailed investigation is
necessary to determine what caused the problem. Step # 4 (Supplier
determines the root cause) requires a 5-Why analysis to help in
identifying the root cause of the problem.
 Going back to one of the elements within the Purpose of a PRR “to
facilitate problem resolution”, 5-Why is the prescribed tool for
determining the root cause of the problem to facilitate problem
resolution.
Where does it fit within the PRR process?

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Is the powerful question… own it!!

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Speed
Limit
Strictly
Enforced
No
Reaction
How
Fast
Are You
Going?
Cause
Reaction
(Look at speedometer)
How
Fast
Should
You Be
Going?
Cause
Reaction & Research
(Look at speedometer;
Search for speed limit sign)
Power of Asking Questions

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Who are the best at asking questions to solve
problems?
Power of Asking Questions

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When working with people to solve a problem,
it is not enough to tell them what the solution is. They need to find
out and understand the solution for themselves. You help them do
this by asking open-ended , thought provoking questions.
Children!
Why?
…because they keep asking objective, open-ended questions until
the answer is simple and clear
Power of Asking Questions

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Close-Ended: Structures the response to be answered
by one word, often “yes” or “no”. Usually
gives a predetermined answer.
Example: “Did the lack of standardization cause the incorrect setup?”
Open-Ended: Leaves the form of the answer up to the
person answering which draws out more
thought or research.
Example: “How is setup controlled?”
Close-Ended vs. Open-Ended Questions

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Benefits of Open-Ended Questions
 Requires thought
 Promotes additional research
 Enhances problem solving skills
 Does not assume there is one right answer
 Avoids predetermined answers
 Stimulates discussion
 Empowers the person answering
In many circumstances, it is not only the answer itself,
but the process by which the answer was determined
that is important when asking an Open-Ended question

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Example 1:
“What could have caused the tool to break?”
(Open-Ended, probing question forces the person to think about all
possibilities, not just PM)
Example 2: “Would improving material flow help reduce lead times?”
(Good question but it’s still Close-Ended, focuses the person on material
flow as a means to reduce lead time. Is this the best improvement?)
“Did the lack of a PM system cause this tool to break?”
(Close-Ended question, can be answered by a “yes” or “no”, gives the
person a predetermined answer that PM is to blame)
“What are some options on improving lead time?
(Open-Ended, triggering more thought and research on all variables
impacting lead time.)
Example 3: “Is equipment capability causing the variation in your process?
(Close-Ended, can be answered by a “yes” or “no”, focuses the person on
equipment being the source of variation)
“What could potentially cause variation in your process?
(Open-Ended, triggering more thought and research, opens up possibilities
of variation with man, material & method, not just machine)
More Examples

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5 Why Overview
?

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5-Why:
Specific problem:
– Why did we have the problem?
Problem not detected:
– Why did the problem reach the Customer?
System failure:
– Why did our system allow it to occur?

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Corrective Action
with Responsibility Date
Define Problem
Use this path for
the specific
Root Causes
A
nonconformance
being investigated
WHY? Therefore
Use this path to
investigate why the
problem was not
detected.
WHY? Therefore
WHY? Therefore B
WHY? Therefore WHY? Therefore
A
Use this path to
investigate the
systemic root cause
(Quality System
Failures)
WHY? Therefore
WHY? Therefore
C
WHY? Therefore WHY? Therefore
B
Ref. No. (Spill, PR/R…) WHY? Therefore
Date of Spill WHY? Therefore
Product / Process Delphi Location Content Latest Rev Date WHY? Therefore
C
Problem Resolution Complete Communicate to Delphi Date: Process Change Break Point Date: Implement System Change Date:
Lessons Learned:

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Delco fuse box
Insert example
What tool do
We use for this?

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 Part I – Grasp the Situation
◦ Step 1: Identify the Problem
 In the first step of the process, you become aware of a problem that may be
large, vague, or complicated. You have some information, but do not have
detailed facts. Ask:
 What do I know?
◦ Step 2: Clarify the Problem
 The next step in the process is to clarify the problem. To gain a more clear
understanding, ask:
 What is actually happening?
 What should be happening?
◦ Step 3: Break Down the Problem
 At this point, break the problem down into smaller, individual elements, if
necessary.
 What else do I know about the problem?
 Are there other sub-problems?

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◦ Step 4: Locate the Point of Cause (PoC)
 Now, the focus is on locating the actual point of cause of the problem.
You need to track back to see the point of cause first-hand. Ask:
 Where do I need to go?
 What do I need to see?
 Who might have information about the problem?
◦ Step 5: Grasp the Tendency of the Problem
 To grasp the tendency of the problem, ask:
 Who?
 Which?
 When?
 How often?
 How much?
 It is important to ask these questions before asking “Why?”

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 Step 1: Problem Statement
◦ Is the problem statement clear & accurate?
◦ Is the analysis on the problem as the customer sees it?
 Step 2: Three Paths
◦ Are all three legs filled in?
◦ Are there any leaps in logic?
◦ Can you ask one, two, or three more Whys?
◦ Is there a cause-and-effect relationship in each path?
◦ Can the problem be turned “on” and “off”?
◦ Does the path make sense when read in reverse?
◦ Do the whys relate to the actual error?
◦ Does the non-conformance path tie to design, operations, dimensional
issues, etc.?
◦ Does the detection path tie to the customer, control plans, etc.?
◦ Does the systemic path tie to management issues or quality system
failures?

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 Step 3: Corrective Actions
◦ Is there a separate action for each root cause?
◦ Is it possible to implement each corrective action?
◦ Do corrective actions require Customer approval? If so, how will they be
communicated to the Customer?
◦ Is there evidence to support verification of corrective actions?
◦ Are corrective actions irreversible?If not, do actions address ongoing
containment?
◦ Is there a plan to standardize lessons learned across products,
departments, etc?
 Step 4: Lessons Learned
◦ How could the problem have been foreseen?
◦ How will information be implemented?
 On the line or in the plant?
 At the point of detection?
 Cross functionally at the Supplier?
 Other products/plants?

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 Step 5: Overall
◦ Are there gaps or “holes?”
 Are there things missed or not documented?
◦ Do corrective actions address actions the Supplier owns?
◦ How many iterations of 5 Why Analysis have there been?
◦ Who prepared the 5 Why Analysis?
 One person?
 Sales representative ?
 Clerk?
 The best answer is a cross functional team that understand the product
and process!

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5-Why Analysis
The problem is stated through the
eyes of the customerProblem
The first why is the main cause
Etc.
You have root cause if you
can demonstrate:
• cause on, problem on
• cause off, problem off
Root Cause
The second why is what causes
the main cause
Etc.

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A good 5-Why will answer “Yes” to the five
PDCA questions:
PLAN
DOCHECK
ACT
1. Is the problem statement
CLEAR and ACCURATE?
2. Has the SYSTEMIC
root cause(s) been
identified for all legs?
3. Has IRREVERSIBLE
CORRECTIVE ACTION(s)
been implemented for
ALL root causes?
4. Has a plan been identified
to verify the
EFFECTIVENESS
of all corrective
actions?
5. Has a plan been identified
to STANDARDIZE and take
all lessons learned across
products, processes,
plants, functional areas, etc.?
Understand the problem
Execute the PlanFollow-up
Standardize
“A problem well defined
is a problem half solved”

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 General Guidelines: A.) Don’t jump to conclusions!; B.) Be absolutely objective. C.) Don’t assume the answer is
obvious. D.) If you are not thoroughly familiar with the process yourself, assemble a cross-functional team to
complete the analysis.
 Step 1: Problem Statement
Is the analysis being reported on the problem as the Customer sees it?
 Step 2: Three Paths (Dimensional, Detection, Systemic)
-Are there any leaps in logic?
-Is this as far as the Whys lead? Can you still ask one, two, three more why’s)?
-Is there a true cause-and-effect path from beginning to end of each path? Is there statistical data/evidence to prove
it? ---Can the problem be turned off and on?
-Does the path make sense when read in reverse from cause to cause? (e.g.—We did this, so this happened, so this
happened, and so on, which resulted in the original problem.)
-Do the why’s go back to the actual error?
-Does the systemic path tie back to management systems/issues?
-Does the nonconformance path ties back to issues such as design, operational, tiered supplier management, etc…?
-Does the detection path ties back to issues such as protect the customer, control plans, etc…?
 Step 3: Corrective Actions
-Does each corrective action address the root cause from a path?
-Is there a separate corrective action for each root cause? If not, does it make sense that the corrective action
applies to more than one root cause?
-Is each corrective action possible to implement?

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-Are there corrective actions that affect the Customer or require customer approval? How will they be
communicated to the Customer?
-Is there evidence and documentation to support the validity of the corrective actions?
-Are the corrective actions irreversible? If not, are there corrective actions in place that address containment?
 Step 4: Lessons Learned
-How could this problem have been foreseen?
-How will this information be implemented:
a.) on the line or in the plant?
b.) at the point of detection?
c.) cross-functionally at the Supplier?
d.) other product/plants?
-Are there lessons learned for the Customer?
 Step 5: Overall
-Do there seem to be big holes where ideas, causes,
corrective actions, or lessons learned are being avoided?
-Where things are missed or not documented?
-Do the corrective actions address the actions the supplier owns?
-How many iterations has the supplier gone through so far in preparing
this 5-why (It doesn’t happen on the first try!)
-Who prepared the 5-why?

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 5-Why Analysis: Green, Yellow, Red
◦ G: Can follow logic and flow of all 3 legs of 5 why's. The legs
all differentiate "What is the problem, why wasn't it
detected, and what happened systemically."
◦ Y: All 3 legs filled out, some leaps of logic, needs minor
corrections to improve.
◦ R: 1 or 2 legs missing, Leg 1 repeated as leg 2 or 3, not
understanding what the different legs mean--typically
missing what the systemic leg is. Poor answers on 2 or more
legs.

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