Why / Why (5 Why) Analysis

At
Honda Cars India Limited

TQM International Pvt. Ltd.

 Agenda
When to use 5 Why
5 Why guidelines
3 stages of 5 Why analysis
5 Why Examples / Exercises
 Seven Steps of Problem Solving
Define the process
Present status
Analyze
Do
Study
Standardize
Review
 If a problem occurs
First is containment
What is after Containment??
Root Cause Analysis
 Five Whys is a Root Cause analysis Tool
Five Whys is a Root Cause Analysis Tool. Not a problem solving technique.
The outcome of a 5 Whys analysis is one or several root causes that
ultimately identify the reason why a problem was originated. There are other
similar tools as the ones mentioned below that can be used simultaneously
with the 5 Whys to enhance the thought process and analysis.

Corrective
Problem Root Cause
Actions

Root cause analysis tool:

Ishikawa Charts (Fish Bone)
Design of Experiments
Is / Is not Analysis
5 Whys
Cause and Effective Diagram
Statistical Data Analysis(Cpk,
Paretto Charts, Anova, etc.)
 When to Use 5 Why
Customer Issues
Required for all Problem Cases
May be requested for informal complaints
May be requested for warranty issues
Internal Issues
Quality System Audit Non-conformances
First Time Quality
Internal Quality Issue
Machine break down
 When to use 5 Why
5 Why Analysis can be used with various
problem solving methods
Internal Problem Solving
GM Drill Deep
Ford 8 D (Discipline)
Chrysler 8 Step
DMAIC (Six Sigma)
5 Why, when combined with other problem
solving methods, is a very effective tool
 Five Whys Guidelines
A cross-functional team should be used to
problem solve
Dont jump to conclusions or assume the
answer is obvious
Be absolutely objective
 Five Whys Guidelines
General Guidelines
If you are using words like because or due to in any box, you will
likely need to the next Why box
Root cause can be turned on and off
Will addressing/correcting the cause prevent recurrence?
If not what is next level of cause?
If you dont ask enough Whys , you may end up with a symptom
and not root cause.
Corrective action for a symbol is not effective in eliminating the cause
Corrective action for a symptom is usually detective
Corrective action for a root cause can be preventive
Path should make sense when read in reverse using Can it cause
that? Test.
 Five Whys Guidelines
Even though the discipline is called 5 Whys is not always
necessary to reach 5 before the root cause of a problem is
fully explained; or it may take more than 5 whys to get the
bottom of it. It will depend on the complexity of the process
or the problem itself. (Normally it is recommended 3 to 5
Whys)
In any case, 5 has been determined; as a rule of thumb, as the
number at which most root causes are clearly identified. Do
not worry about meeting or exceeding this number though.
Just follow your thought process and let it decide how many
Whys you require to get the point where the root cause is
evident.
 Five Whys Guidelines
For all the Five Whys:
Ask the full question including the problem or cause behind it. If
there is a problem with labeling ask :
Why the parts were labeled incorrectly?
If the answer is unreliable database ask :
Why is the database unreliable?
If we do not follow this
approach answers to
the whys tend to loose
focus on the third or
fourth why.
 Five Whys Guidelines
It is said that a well designed problem is a half
resolved; hence it is important to state the
problem as clearly as possible.
Whenever possible define the problem in
terms of the requirements that are not being
met. This will add a reference to the condition
that should be and is not.
 Five Whys The First Why
Clear statement of the reason of the reason for the
defect or failure to occur, understood even by people
who are not familiar with the operation where the
problem occurred.
Often the 1st Why must be a short, concise sentence
that plainly explains the reason. Do not try to justify
it, there will be time to do that later on in the
following whys if it is pertinent to the thought
process. It is Ok to write it down even if it seems too
obvious for you. (it may not seem that obvious to
other persons that will read the document).
 Five Whys The Second Why
A more concise explanation to support the
first statement.
Get into the technical arena, the explanation
can branch out to several different root causes
here. It is OK to follow each of them
continuing with their own set of remaining 3
whys and so forth.
 Five Whys The Third Why
Do not jump to conclusions yet, follow the regular thought
process even though some underlying root causes may start
surfacing already.
This 3rd why is critical for a successful transition between the
obvious and the not so obvious. The first two whys have
prepared you to focus on the area where the problem could
have been originated; the last three whys will take you to
deeper comprehension of the problem. Visualize the process
where the product went through (process mapping) and narrow
down the most likely sources for the problem to occur.
You do not need to answer all the whys at the same time. It is
an investigation activity and it is good practice sometimes to go
to the process and see things you could have missed at first.
You may be missing the obvious by rushing into logical
explanations.
 Five Whys The Fourth Why
Clear your mind from preconceived explanations and start the
fourth why with a candid approach. You may have two or more
different avenues to explore now, explore them all. Even if one or
several of them turn out not to be the root cause of the problem,
they may lead to continuous improvements.

This is a good time to include a Cause and Effect analysis and look at
the 5 Ms
Method
Material
Manning
Machines
Mother Nature
 Five Whys The Fifth Why
When you finally get to the fifth why, it is likely that you
have found a systematic cause. Most of the problems in
the process can be traced to them. Even a malfunctioning
machine can sometimes be caused by an incorrectly
followed Preventive Maintenance or Incorrect machine
parameters setup.
When you address a systematic cause, do it across the
entire process and detect areas that may be under the
same situation even if there are no reported issues yet.
If you have reached the fifth why and you are still dealing
with process related cause(s), you may still need one or
two more whys to deep dive into the systemic cause.
 Five Whys
Using the Cause and Effect diagram with the major categories,
begin with the most likely the questioning of why.
Root Cause Most Basic Reason a Problem Has or Could Occur
1. Ask why 3-5 times. Progressively becomes more difficult
and more thought provoking
- Why is this failure mode active ? assignment.

Symptom 1 Early questions are usually

superficial, obvious; the later ones
Why Symptom 2 more substantive.
Why Symptom 3
Why Symptom 4
Why did this
happen ? And more why Probable Root cause
 Five Whys (continued)
2. Get to something Actionable.
Something can be done that will, if fixed, prevent problem form existing or
recurring.
You or your department can do something about the probable root cause. (Do
you have control over the probable root cause? )
Revisit each sub-bone for additional causes move back to symptom 3 and
ask again, why does this symptom occur? Next, why does symptom 2
occur? Continue asking why back to the major bone (category).
Complete the entire cause and effect diagram using this same
methodology.
Identify the most likely root causes and circle or cloud them the last
element in the chain you identified. (Hint: sometimes the causes most
repeated are a good place to start.)
Verify the potential root causes using data. Remember its not enough that
the root causes exist where the problem occurs. You must also verify that
the root cause doesnt exist where the problem doesnt exist.
 Five Whys (continued)
3. Check the logic in reverse direction
Probable root cause can it cause symptom 4 to occur
Symptom 4 can it cause symptom 3 to occur
Symptom 3 can it cause symptom 2 to occur
Symptom 2 can it cause symptom 1 to occur
Symptom 1 can it cause failure

Why is this failure mode active ?

Symptom 1
Symptom 2
Symptom 3
Symptom 4
Probable Root
cause
 Five Whys - (continued)
4. Check the logic from probable root cause to problem/top event.
If the probable root cause is eliminated or corrected, would it prevent the
problem from existing or occurring ?
When the probable root cause occurs, does the problem occur?
5. No procedure and no training are usually potential solutions, not
a potential root cause.

No Procedure No Training

Identify the Knowledge Gap Identify the Skill Deficiency

 Five Whys - (continued)
Another good way to identify whether the 5 Whys was done
properly is to try to organize the collected data in one sentence
and define it in an understandable manner. If this cannot be
done or the sentence is fragmented or meaningless chances are
that there is gap between one or several of the whys. You then
must revisit the 5 Why and identify those gaps to fill them in. If
there is coherence in the way that the sentence is assembled, it
shows consistency on the thought process.
Something like :
Problem Description occurred due to Fifth Why. This was
caused by Fourth Why mainly because Third Why was
allowed by Second Why, and this led to First Why.
 Five Whys (continued)
Do not forget that the sought outcome of a 5 Why exercise
is a root cause of the defined problem, not the resolution
of the problem itself; that will come later. 5 Whys is not a
standalone Problem Solving technique but more of a tool to
aid in this process of getting to root cause.
Do not worry about Action plans and effectiveness
verification yet as that comes later; but focus more on
identifying the reason that allowed the problem to happen
and escape. If you can come up with a reasonable answer,
the 5 Whys exercise would be successful. If it cannot be
done, then quite probably more data needs to be collected
to get a better grip of the problem and them the 5 why
process can be restarted.
 Five Whys (continued)
Once again final point to ponder :
A PROBLEM THAT
CANNOT BE REPRODUCED
IS A PROBLEM THAT HAS
NOT BEEN RESOLVED YET.

Challenge the root cause(s) that resulted from the 5 Whys

exercise to try to reproduce the defect. If you cannot there is
a very big chance that you have not reached to the bottom of
it yet. If you do reproduce them, move on to the Corrective
Action plan and congratulate your team for a job done well.
 Three Stages of Five Whys
Any 5 Whys must address three different problems at the same time.

The first part is specific related to the process that made the
defective part.

( Why made? )

The second one must address the detection system that was not
able to detect the defection part before it became a problem. The
lack of detection of a defective product is a problem of its own and
must be treated independently than the product problem itself.

( Why not detected? )

 Three Stages of Five Whys
The third part is (Systemic) system related
which allowed the product, process or system
design which did not foresee the failure and
built fail safe product / process or system.

( Why did our system allow it to occur ? )

 3 Stages, 5 Why Analysis
Define Problem Use this path for the specific non
conformance being investigated
Why? Root Causes

Why?
Why?
Use this path to investigate why
the problem was not detected
Why?
A
Why?

Why?
Use this path to investigate Why?
the systemic root cause
Why?
B
Why?
Why?

Why?
Why?
C
Why?
 Specific
Define the problem
Problem statement clear and accurate
Problem defines 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
Specific Problem
Why dis 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
Specific Problem
Root Cause Examples
Parts damaged by shipping dropped or stacked
incorrectly
Operator error poorly trained or did not use proper
tools
Operator error performed job in wrong sequence
Changeover occurred wrong parts used
Processing parameters changed
Excessive tool wear/breakage
Machine fault machine stopped mid-cycle
 Specific
What if root cause is?

Operator did not

follow instructions

Do we stop here?
 Specific Problem
Operator did not
follow instructions

Do standard No
work Create a standard
instructions instruction
exist ?

Yes
No
Or do we attempt Is the
operator Train Operator
trained ?
to find the root
Yes
cause ? Were work
instructions
No
Create system to assure
correctly
followed ? conformity to instructions

Yes
Are No Modify instructions &
instructions
effective ? check effectiveness

Yes
Yes Do you have No
the right
person for this
job/task ?
 Specific
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 Can it cause

lodged below shoe that ?
preventing full travel

Screw fell off gun while

pallet was indexing
WHY??
Magnet on the screw bit
was weak

Exceeded the bits

workable life
 Specific
Specific Problem
Loss of torque at rack
inner tie rod joint

Undersized chamfer
(thread length on rack)

Part shifted axially

Can it cause
during drill sequence that ?
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
 Example: 5 Whys
Why? Missing CSR did not CSR did not
Why? Why? Why? No guidelines Investigate
information to collect all know pertinent
required info
provided to
complete info for each
application for customer types of loan CSR

Insufficient Most apply To spend long

Why? Why? leaves on Why? weekends with
human Monday & friends and
End
resources Friday family
Had to wait Why?
for
information Application First level Not confidence
needs 2
Why? Why? Check and Why?
1st level can
Investigate
recommends
balance system evaluate
approval and next level
approves to manage risk effectively
levels

Interfacing
High IT Frequent Different
problems between Why? Investigate
system Software applications and technology
Why? downtime Why? crash Why? credit check platforms
systems
 Example: 5 Whys
First why: Why did the machine stop ? Because the fuse blew due to
an overload.
Second why: Why was there an overload ? Because the lubrication was
inadequate.
Third why: Why was the lubrication inadequate ? Because the
lubrication pump was not functioning right.
Fourth why: Why wasnt the lubrication pump working right ? Because
the pump shaft was worn out .
Fifth why: Why was the shaft worn out ? Because there was no
strainer attached where it should be , letting metalcutting chips in.

By asking why until you reach the root cause you can find a
sustainable solution, such as attaching a strainer to the lubricating
pump.
 Example: 5 Why
5 WHY ANALYSIS GOOD EXAMPLE
Employee injured Hand

Hand clamped in robot

Safety screen failed

Why?
Safety screen defective

Inadequate installation

No checks at installation
 Exercises
Groups to select problem to be analyzed though 5
Whys from their respective area of work

Or take one of the following problem

Steering Hard
Door rattling sound
Uneven tyre wear
Horn works intermittently or does not work
 Detection
Detection:
Why did the problem reach the customer?
Why did we did 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 work
 Detection
Detection
Example Root causes
No detection process in place cannot be detected in
our plant
Defect occurs during shipping
Detection methods failed sample size and frequency
inadequate
Error proofing not working or bypassed
Gage not calibrated
 Detection
Detection
Column would not lock
in tilt position 2 & 4

On-line test for tilt function

is not designed to catch this
type of defect

Test for tilt function is Can it cause

applied before shifter that ?
assembly

Process flow designed in this

manner would not detect
WHY?? shifter ass screw lodged below
tilt shoe
 Detection
Detection
Loss of torque at rack
inner tie rod joint

Undersized chamfer/
thread length
undetected

Inspection frequency is Can it cause

inadequate. Chamfer gage that ?
is not robust

Process CPK results did not

reflect special causes of
WHY?? variation affecting chamfer
 Systemic
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 failure
Rework/repair not considered in process design
Lack of effective Preventive Maintenance system
Ineffective Advanced Product Quality Planning (DFMEA, PFMEA, Control Plans)
Typically traceable to or controllable by Support People
Management
Purchasing
Engineering
Policies/Procedures
 Systemic Issues
Systemic
Helpful hint: The root cause of the specific problem step is
typically a good place to start the systemic stage.
Root Cause Examples
Failure mode not on DFMEA, PFMEA
Believed failure mode had zero potential for occurrence
New product/process not properly evaluated
Product, sub-process, Process changed creating a new failure
cause
DFMEAs, PFMEAs generic not specific to the process
Severity of defect not understood by team
Occurrence ranking based on external failure only, not actual
defects
 Systemic
Systemic
Root Cause
Column would not lock
in tilt position 2 and 4

Detection for tilt function

done prior to installation
of shifter assembly

PFMEA did not identify a Can it cause

dropped part interfering that ?
wit tilt function

First time occurrence for

WHY?? this failure mode
 Systemic
Systemic Root Cause
Loss of torque at rack
inner tie rod joint

Ineffective control plan

related to process related to
process parameter control
(chamfer)

Low severity for

Can it cause
chamfer Control that ?

Dimension was not

considered an important
WHY?? characteristic additional
control not required

Insufficient evaluation of
machining process and
related severity levels during
APQP process
 Corrective Actions
Corrective Actions
Corrective action for each root cause
Look for 2 to 3 alternatives actions for each cause
and choose the best one
Corrective actions must be feasible
Foresee consequential effects of each action
If customer approval required for corrective
action, this must be addressed in the 5 why timing
Corrective actions include documentation updates
and training as apporpriate
 5 Why Critique Sheet
General Guidelines:
Dont jump to conclusionsdont assume the answer
is obvious
Be absolutely objective
A cross-functional team should complete the analysis

Step 1 : Problem Statement

State the problem as the Customer sees itdo not
add cause to the problem statement
 5 Why Critique Sheet
Step 2 : Three Stages (Specific, Detection, Systemic)
There should be no leaps in logic
Ask why as many times as needed. This may be fewer than 5 or
more than 5 Whys(Normally it is 3 to 5 whys)
There should be a cause and effect path form beginning to end
of each path. There should be data/evidence to prove the cause
and effect relationship
The path should make sense when read in reverse form cause to
cause this is the can it cause this test (e.g. did this,
therefore this happened)
The specific problem stage should tie back to issues such as
design, operations, supplier issues, etc.
The detection stage should tieback to issues such as DFMEA,
PFMEA, control plans, error-proofing, etc.
 5 Why Critique Sheet
Step 3: Corrective Actions
There should be a separate corrective action actions for each root
cause. If not does it make sense that the corrective action applies
to more than one root cause?
The corrective action must be feasible
If corrective actions require Customer approval, does timing
include this ?
Step 4: Lessons Learned
Document what should be communicated as Lessons Learned
Within the plant
Across plants
At the supplier
At the Customer
Document completion of in-plant Look Across (communication of
Lessons Learned) and global Look Across
 5 Why Analysis Examples
Group Exercise
Review a 5 Why using the Critique Sheet and what you
have learned
Note: These are actual responses as sent to our Customers!
Has probable root cause been determined for:
Non-conformance stage
Detection stage
Systemic stage
Do corrective actions address root cause?
Have Lessons Learned /Look Across been noted?
If any above answers are no, what recommendations would
you make to the team working on the 3 stages of 5 Why?
Missing O-ring on part
number K10001J

Why ?

Part missed the O-ring

installation process

Why ?
Why did they have
to rework?
Parts had to be reworked

Why ?
Operator did not return
parts to the proper
process step after rework
Why ?

No standard rework
This still a systemic failure procedures exist
needs to be addressed, but
its not the root cause.
 Missing threads on
fastener part number
LB123
Why ?

Did not detect threads

were missing

Why ?
What caused the
Sensor to detect thread
sensor to get
presence was not working damaged ?
Why ?

Sensor was damaged

Why ?
No system to assure
sensors are working
This is still a systemic failure & needs to properly
be addressed, but its not the root cause
of the lack of detection.
 Summary of Key Points
When do you use it?
Use a cross-functional team
Never jump to conclusions
Ask WHY until you can turn it off Use the Can it cause
that? test for reverse path
Strong problem definition as the customer sees it
Specific stage Typically applies to people doing work
Detection stage Typically applies to people doing work
Systemic stage Typically applies to support people Start
with root cause of specific stage
Corrective actions with date and owner
Document lessons learned and look across