This document outlines training on 5 Why analysis. The training will cover: 1. The importance of asking questions to understand problems, with a focus on open-ended questions. 2. Differentiating between technical root causes versus systemic root causes. Technical root causes are directly related to problems, while systemic root causes allow technical issues to occur. 3. Using the 5 Why technique to drill down through a series of "why" questions to uncover the deepest root cause by addressing causes and effects. The goal is to find root causes that can be addressed with countermeasures.

1. 3 X 5 Why Analysis Training
By: Ninia Didulo

2. Training Outline
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I. The POWER of asking question
II. The type of Question that will mean a lot
III. Back to Basics
IV. History and beyond
V. The heart of 5 Why Analysis

3. Training Objectives
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At the end of the course, the participants are expected to:
– Acquire a clear understanding on the importance and
purpose of Why-Why Analysis
– Learn the techniques how to generate a “customer ready and
acceptable” Why-Why Analysis
– Be able to differentiate the Technical Root cause against
Systemic Root Cause
– Apply the Why-Why Analysis effectively when there are
quality issues in his/her area of responsibility

4. Training Requirement
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– Stay focus
– Participate
– Adapt to the changes….
– Ready your “inquisitive MIND”
– Enjoy the training
S P A R E!

5. The POWER of asking Question
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Why
are you here today?

6. The POWER of asking Question
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“If you don’t ask the right questions, you don’t get the
right answers.
A question asked in the right way often points to its own
answer.
Asking questions is the ABC of diagnosis. Only the
inquiring mind solves problems.”
– Edward Hodnett

7. The POWER of asking Question
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What is the right question?
a. When are you going to sleep?
or
b. what time are you going to
sleep?

8. The POWER of asking Question
Who are the best at asking questions?

9. The POWER of asking Question
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- because they keep asking objective, open-ended questions until
the answer is simple and clear

10. The POWER of asking Question
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11. Closed-Ended vs. Open-Ended 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?”

12. Example 1:
“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 could have caused the tool to break?”
(Open-Ended, probing question forces the person to think about all
possibilities, not just PM)
Closed-Ended vs. Open-Ended Questions
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13. 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?)
“What are some options on improving lead time?
(Open-Ended, triggering more thought and research on all variables
impacting lead time.)
Closed-Ended vs. Open-Ended Questions
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14. 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)
Closed-Ended vs. Open-Ended Questions
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15. Benefits of Open-Ended Questions
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Does not assume there is one right
answer
 Promotes additional research
 Requires thought
?

16. Benefits of Open-Ended Questions
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 Avoids predetermined answers
 Enhances problem solving
skills
 Stimulates discussion

17. Benefits of Open-Ended Questions
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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
 Empowers the person answering

18. Fundamentals of Problem Solving
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The word “failure” is abstract. Each defect of a product or
service is a failure. You can only eliminate failures in case you
know the root cause.
Root Cause is. . .
A process factor which directly
defines the reason for the
problem (failure) when it is
present and is having an
influence on the process and
its output.

19. Fundamentals of Problem Solving
Initial problem feedback
Identify/ Clarify the problem
Team Brainstorming for
Potential Root Causes
Test the Hypothesis
Zoom
In
Decide on the
Point of cause
Cause Analysis
using 3x5 HY
Analysis
Grasp the
Situation,
understanding the
problem
Tools:
Hypothesis Table
IS / IS NOT Table
Cause & Effect or
(Ishikawa /Fishbone)
Fault Tree
Etc…
Why?
Why?
Why?
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Fundamentals of Problem Solving –
Understanding the problem
Unit Analysis
Lot to Lot Commonality
4M History / Events
Is – Is Not Analysis

21. Fundamentals of Problem Solving – RCA Tools
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22. The 5 WHYs…
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• Method was developed by Sakichi Toyoda
• Was incorporated to the Toyota Production System
(architect by Taichi Ohno) as a critical component
of problem solving training
• Objective: reach the real root cause
• Ask several times the question Why until you hit
the real root cause

23. Sample Why-why Analysis:
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Why1."Why did the robot stop?"
- The circuit has overloaded, causing a fuse to blow.
Why2. "Why is the circuit overloaded?"
- There was insufficient lubrication on the bearings, so they locked up.
Why3. "Why was there insufficient lubrication on the bearings?"
- The oil pump on the robot is not circulating sufficient oil.
Why4. "Why is the pump not circulating sufficient oil?"
- The pump intake is clogged with metal shavings.
Why5. "Why is the intake clogged with metal shavings?"
- There is no filter on the pump.

24. 3X5 WHY Solution Pattern
Method: The problem solver simply asks a Why-question approximately
five times in series in 3 dimensions:
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PREVENT PROTECT
PREDICT
1
The Occurrence
(non conformity )
Why do we have the
problem?
2
The Escape
(non detection )
Why did we not
detect the
problem?
The System
(predictive/preventive)
Why did the system
allow this problem to
happen?
3

25. Technical Root Cause vs System Root Cause
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Each failure has a Technical Root Cause (TRC) that is directly
related to the symptom. Some failures can have more technical
causes.
Failures occur not intentionally but they occur systematically.
That means that behind the TRC there is a (Managerial)
Systemic Root Cause (SRC), that allows the TRC to happen

26. Technical Root Cause vs System Root Cause
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27. Technical Root Cause vs System Root Cause
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28. Basic 5-Why Solution Pattern
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The 5-Why method of root cause analysis requires you to question how the sequential
causes of a failure event arose and identify the cause-effect failure path. ‘Why’ is asked to
find each preceding trigger until we supposedly arrive at the root cause of the incident.

29. Basic 5-Why Solution Pattern
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30. Sample Technical RC (Non Conformance)
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Problem : The part does
not work in the ABC
application
12 V output voltage is below limit
(zero)
The maintenance of the
etching chambers is not
frequent enough to be
effective, 1x a day only
There is an open
connection on the traces
There is an FM below
the metal
The etching process
is insufficient to
remove the XX size
metal
Thus
Thus
Thus
Thus
Thus
Why ?
Why ?
Why ?
Why ?
This is a
Technical
occurrence
root cause
5 Why’s is not finished here:
You need to understand why the
organization did not predict
Failed to inspect
Non conformance on procedure

31. Sample System RC of TRC
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The maintenance of the
etching chambers is not
frequent enough to be
effective, 1x a day only
Maintenance procedure is
obsolete
It has not been updated
since last year
Quality system requests an update
only each 2 years, this type of
equipment acquire past the review
Why?
Thus
Thus
Thus
Why?
Why?
This is an
occurrence
system root
cause

32. Sample Technical RC (Non Detection)
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Problem : the part does
Test at the customer indicates
an output voltage < 12 V
The OS test did not
detect the bad part
The test program
does not test the
Voltage Out pin
not work in the ABC
application
Why?
Why?
Why?
Why?
Not considered during test
program qualification
Thus
Thus
Thus
Thus
This is a
Technical
escape
root cause
5 Why’s is not finished here:
You need to understand why
your organization did not predict
that

33. Sample Escape System RC
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Voltage Out Pin Not
considered during test
program qualification
Voltage Out pin considered
Non-critical
Patterned on the old
devices review checklist
Inadequacy in the device
qualification procedure, no
provision on new device critical
check items review
Why?
Thus
Thus
Thus
Why?
Why?
This is an
Escape
system
root cause

34. Missing threads
on fastener part
number LB123
Did not detect
threads were
missing
Sensor to detect
thread presence
was not working
Sensor was
damaged
WHY?
WHY?
WHY?
WHY?
No system to
assure sensors are
working properly
This is still a systemic failure
& needs to be addressed,
but it’s not the root cause
of the lack of detection.
Is this a good or bad “TRC” ?
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What caused
the sensor to
get damaged?

35. Missing o-ring
on part number
K10001J
Parts missed the
o-ring installation
process
Parts had to be
reworked
No standard rework
procedures exist
WHY?
WHY?
Operator did not return
parts to the proper process
step after rework
WHY?
WHY?
Is this a good or bad Escape RC?
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Why did they
have to rework?
This is still a systemic failure
& needs to be addressed,
but it’s not the root cause.

36. Basic 5-Why Solution Pattern Template – with CAPA
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37. Ten Basic 5WHY Rules
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38. Ten Basic 5WHY Rules
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39. Ten Basic 5WHY Rules
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No business can be continued with this rootcause!

40. Ten Basic 5WHY Rules
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41. Ten Basic 5WHY Rules
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42. Ten Basic 5WHY Rules
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43. Ten Basic 5WHY Rules
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44. Ten Basic 5WHY Rules
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45. Ten Basic 5WHY Rules
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46. Ten Basic 5WHY Rules
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47. When do I stop asking “Why” ?
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Repeat the “why” until the answer can trigger a countermeasure

48. Ten Basic 5WHY Rules
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