Transcript: The 5 Whys The 5 Why Technique TECHNIQUE A repetitive question-asking technique used to examine and analyze the cause-and-effect relationships underlying a specific issue or problem. The goal of this procedure is to establish the ROOT CAUSE of a deficiency, problem or error. 1. Write the problem statement. How to Use the 5 Whys 2. Think about why the problem occurred and write the answer down. 3. If this "WHY" does not thoroughly answer the initial question, ask "WHY" again, and write the answer down. 4. Continue to ask "WHY" until you and your team have identified the ROOT CAUSE of the problem. DIRECT CAUSE The cause that directly resulted in an event. The first link in the causal chain. CRITICAL 5 CONTRIBUTING CAUSE The cause that contributed to the event, but by itself would not have caused the event. The cause after the direct cause. ROOT CAUSE The fundamental reason for an event, Which is corrected, would prevent recurrence. The last cause in the causal chain. CORRECTION CORRECTIVE ACTION Action (s) taken to correct or change the event (effect). Corrects or improves the condition noted in the event. Action (s) taken that prevent recurrence of the condition noted in the event. Corrective Actions must directly address the root causes, contributing causes, and direct causes to be effective. 1 2 3 4 5 SURF U R F Use 5W1H S State the Problem Ask “Is there more than one problem?” Keep It Simple Understand the Situation Collect Data Verify the data Make sure you're on target Root Up the Cause Identify the Direct Cause (1st Why) Identify the contributing cause (2nd Why-4th Why) Identify the root-cause (within control) Fix it and Make It Stay Fixed Know your team & Brainstorm (Ask the right questions) Perform corrective action Follow-up & Measure effectiveness
Transcript: WHY? WHY?WHY? V Hemant Saran 35052 Tanker Prices to remain high Dec 12,2019 Headline:Headline:Tankers Rates to remain high on tight capacity, Plentiful Crude WHY? 1 STEP Why? Vessel Operators are holding back on ordering new ships and Forecasts suggests an oil supply glut will persist in early 2020 2 STEP From September, there has been a series of geopolitical events which had triggered this WHY? WHY? WHY? 3 STEP WHY? President Trump put sanctions on tankers run by a unit of Chinese state owned Cosco Shipping Energy Transportation Co. WHY? 4 STEP WHY? They were allegeldy transporting Iranian oil in violation of sanctions WHY? WHY? The longer routes command higher prices
Transcript: TTTeam Meeting The Five Whys Overview Overview The five whys is asking 'why' five times in order to understand the root cause of something Problem Statement: You are on your way home from work and your car stops in the middle of the road. 1. Why did your car stop? – Because it ran out of gas. 2. Why did it run out of gas? – Because I didn’t buy any gas on my way to work. 3. Why didn’t you buy any gas this morning? – Because I didn’t have any money. 4. Why didn’t you have any money? – Because I lost it all last night in a poker game. 5. Why did you lose your money in last night’s poker game? – Because I’m not very good at “bluffing” when I don’t have a good hand. Why Why we are doing this This is a method of combating 'fire' situations and communication in general Exercise Exercise 1) Find a partner 2) Ask your partner about a current task they are doing 3) Ask why they are doing that task 4) Continue with asking four more why questions 5) Switch sides Reflection Reflection Was it hard to answer why? What did you learn about the other person? Why might it be important to understand why you are doing what you are doing? Other... Wrapping up How might you use this in your work? Results PHASE 1: PHASE 2: PHASE 3:
Transcript: 5 Whys Student's names: Christian Juan Carlos Flores Hernandez, Marcos Guerrero Ramírez, Miguel Angel Bustamante Frias, Noé Servando Escalante Guerrero Subject: Project engineering/ Professor: Sergio Alejandro Pérez Romero Academic Area: Mechatronics Engineering/ Group: GIME10093-s Unit I: Quality tools Project engineering 5 Whys It’s just as it sounds: A discussion of the unexpected event or challenge that follows one train of thought to its logical conclusion by asking “Why?” five times to get to the root of what happened. SUMMARY SWOT Analysis The origin of the 5 Whys The 5 Whys technique was developed and fine-tuned within the Toyota Motor Corporation as a critical component of its problem-solving training. Taiichi Ohno, the architect of the Toyota Production System in the 1950s. “The basis of Toyota’s scientific approach . . . by repeating why five times, the nature of the problem as well as its solution becomes clear.” Logic of the 5 whys Many organizations use a strict interpretation of the 5 whys, where the fifth reason is known as the root cause. Asking "Why?" A number of times is a simple way to begin the analysis of a problem, but there is nothing special about number five - apart from being after four and before six. FOCUS AREA 1 Welding Robot Stopped Taiichi Ohno published in March 2006 an article on 5 whys applied to the arrest of a welding robot, where he recommends "Ask 'why' five times on any problem." THE PROBLEM THE PLAN THE PLAN THE TIMELINE THE TIMELINE 2013 2015 2017 2019 FOCUS AREA 2 FOCUS AREA 2 THE PROBLEM THE PROBLEM THE PLAN THE PLAN THE TIMELINE THE TIMELINE 2013 2015 2017 2019 FOCUS AREA 3 FOCUS AREA 3 THE PROBLEM THE PROBLEM 75 % 35 % 10 % THE PLAN THE PLAN THE TIMELINE THE TIMELINE 2019 2013 2017 2011 2015
Transcript: The time invested overall, and at each Why level, should be proportional to the size of the problem. Evolving a great software process 1) Cowboy 2) Architect 5 Whys Find all causes of a problem. Fix All Whys 2 Roads to FAIL Anti-fragile google it Even if spending 10 hours on this one why level of this minor issue could resolve it forever, lets just spend the first hour now. The issue is so minor and may never crop up again and if it does, we can spend the second hour. Site Down -Why? Server Crashed - Why? Service Called the wrong Way - Why? Dev didn't know right way - Why? Because never document - Why? Team too busy Proportional Investment Fix Server Improve web service Educate the Dev Improve the documentation The Five Whys And Proportional Investment Make a proportional investment in each. Proportional Investment Example Also Google: Hill Climbing Algorithm Hormesis Cluster Immune System There will never be enough time for the perfect solution. That is ok, we are evolving towards it. Proportional Investment Minor Problem, Minor Investment 5 Whys helps us find the middle path
Transcript: The5Whys 1 Sakichi Toyoda is the inventor of Toyota and inventor of The 5 whys. The 5 Whys are a method that helps you did deeper on a problem. How it works is you start off with the general question why is this happening. After narrowing it down What are The 5 Whys The delivery was late, so the leaflets couldn’t be used The job took onger than we expected We ran out of printer ink The ink was all used on a large, last-minute order We didn’t have enough ink in stock, and couldn’t order new supplies in time 2 January 20 3 Customize the Template 4 An Important Event 5 Click to edit text
Transcript: Use the following tests to check the validity of your root causes: -Is it possible to take action on the identified root cause? Keep in mind that one of the main reasons for doing root cause analysis is to implement corrective actions, so the root cause must be actionable -Can I still find more actionable root causes if I ask Why? one more time? If so, the real root cause has not been found yet. -Will the implemented actions ensure that the issue will not happen again? This is the main purpose for doing the root cause analysis; we don't want the same thing to happen again for the same reason. What is Root Cause Analysis (RCA)? - RCA is a term used to describe a method of investigating an issue down to its most probable cause. RCA "digs deeper" to identify the failure of a process control (e.g. equipment failure due to inadequate preventative maintenance) or organizational factor (e.g. lack of skills or inadequate training) - Specifically we will look into how to use one of the RCA tools There can be multiple root causes for one incident Identify the previously unidentified risks Most often the root cause is not human factor based; usually it's a breakdown in the process. Pay attention to a break down of the system lack of training or inadequate training lack of or inadequate work instructions 5 Why Method 7:25pm May 6, 1937 Lakehurst Naval Base, NJ Hindenburg Fire/Crash 36 People killed Complete loss of Hindenburg While dropping anchor ropes for landing the airship suddenly burst into flames causing panic on the ground and the airship to crash. The Hindenburg was a hydrogen filled airship (blimp) capable of carrying 97 passengers, and was capable of crossing the Atlantic Ocean. Important Notes to Remember for RCA The sooner you can fix the problem, the cheaper it will be. 5 Why Method Phase 3 - Resolution of Occurrence Assessment of viability of the potential corrective actions associated with phase 2 outputs. Include a verification step when at all possible Why do we use 5 Whys? RCA Investigation Activity Goals of RCA Pro's; basic thought process and broad thinking Con's; Often only addresses 1 root cause, repeatability of results can vary March 25, 1911 New York, New York Triangle Shirt Waist Fire Testing the root causes 1) Avoid thunderstorms by a pre-determined distance 2) Use less flammable mix of flame retardant as tje waterproofing 3) Use Alternate fuel 4) Use inerting process to isolate fuel gas from air (removing a leg of the fire triangle) 5 Why is a base tool that can be used by itself or inside the other methods. In one of the darkest moments of America's industrial history, the Triangle Shirtwaist Company factory in New York City burns down, killing 145 workers, on this day in 1911. The tragedy led to the development of a series of laws and regulations that better protected the safety of factory workers. The Triangle factory, owned by Max Blanck and Isaac Harris, was located in the top three floors of the 10-story Asch Building in downtown Manhattan. It was a sweatshop in every sense of the word: a cramped space lined with work stations and packed with poor immigrant workers, mostly teenaged women who did not speak English. At the time of the fire, there were four elevators with access to the factory floors, but only one was fully operational and it could hold only 12 people at a time. There were two stairways down to the street, but one was locked from the outside to prevent theft by the workers and the other opened inward only. The fire escape, as all would come to see, was shoddily constructed, and could not support the weight of more than a few women at a time. Blanck and Harris already had a suspicious history of factory fires. The Triangle factory was twice scorched in 1902, while their Diamond Waist Company factory burned twice, in 1907 and in 1910. It seems that Blanck and Harris deliberately torched their workplaces before business hours in order to collect on the large fire-insurance policies they purchased, a not uncommon practice in the early 20th century. While this was not the cause of the 1911 fire, it contributed to the tragedy, as Blanck and Harris refused to install sprinkler systems and take other safety measures in case they needed to burn down their shops again. Added to this delinquency were Blanck and Harris' notorious anti-worker policies. Their employees were paid a mere $15 a week, despite working 12 hours a day, every day. When the International Ladies Garment Workers Union led a strike in 1909 demanding higher pay and shorter and more predictable hours, Blanck and Harris' company was one of the few manufacturers who resisted, hiring police as thugs to imprison the striking women, and paying off politicians to look the other way. On March 25, a Saturday afternoon, there were 600 workers at the factory when a fire broke out in a rag bin on the eighth floor. The manager turned the fire hose on it, but the hose was rotted and its valve was rusted shut. Panic ensued as
Transcript: 1 2 3 4 5 Why's SIE 383 Group 8: Elizabeth Gyek Brent McFarland Ben O'Rourke David Warnes It's a great Six Sigma tool that doesn't involve data segmentation, hypothesis testing, regression or other advanced statistical tools, and in many cases can be completed without a data collection plan. Example of 5 Why's Logic Chain Broken Leg caused by Falling caused by Wet floor caused by Leaky valve caused by Broken seal caused by Poor maintenence 5 Whys And The Fishbone Diagram When Is 5 Whys Most Useful? Problems involve human factors or interactions Day-to-day business life Within or without a Six Sigma project "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 Questions? DMAIC Benefits of the 5 whys How To Complete The 5 Whys Sources: http://www.isixsigma.com/index.php?option=com_k2&view=item&id=1308:determine-the-root-cause-5-whys&Itemid=200 http://www.youtube.com/watch?v=IETtnK7gzlE&feature=related Six Sigma The 5 Whys can be used individually or as a part of the fishbone (also known as the cause and effect or Ishikawa) diagram. The fishbone diagram helps you explore all potential or real causes that result in a single defect or failure. Once all inputs are established on the fishbone, you can use the 5 Whys technique to drill down to the root causes. 1. Write down the specific problem. Writing the issue helps you formalize the problem and describe it completely. It also helps a team focus on the same problem. 2. Ask Why the problem happens and write the answer down below the problem. 3. If the answer you just provided doesn't identify the root cause of the problem that you wrote down in step 1, ask Why again and write that answer down. 4. Loop back to step 3 until the team is in agreement that the problem's root cause is identified. Again, this may take fewer or more times than five Whys. Help identify the root cause of a problem Determine the relationship between different root causes of a problem One of the simplest tools; easy to complete without statistical analysis
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