3 Legged “5 Why” Root Cause Analysis Making Customers Central To All That We Do April 24, 2014 John Heise, CLSSMBB, CQM, Iowa Quality Center

3 Legged “5 Why” Root Cause Analysis Training Course Objectives Understand the purpose of 3 legged “5 Why” (“3x5 Why”) Root Cause Analysis Learn the basic components of a “3x5 Why” Develop the skills needed to perform a “3x5 Why” Analysis with confidence I hear, I forget. I see, I remember. I do, I understand. - Chinese Proverb Objectives: - Understand the purpose of 3x5 Why - Learn the basic components of a 3x5 Why Root Cause Analysis - Develop the skills needed to do a 3x5 Why Root Cause Analysis with confidence

3x5 Why Root Cause Analysis What is it? The “5 Why’s?” is the most basic form of Root Cause Analysis Simple: Ask “why?” until you can’t ask “why?” anymore Focused on a particular problem or effect: typically undesirable “3x5 Why’s?”: an approach to determine all possible causes that lead to the effect (issue) Broken down into three key areas: Direct Cause: The Immediate reason for the effect Detectability: Reason nonconformity was not caught Systemic Cause: Reason system allowed problem to occur What is it? - The "5 Why's?" is a basic form of Root Cause Analysis - A simple process of asking "why" until you can't ask "why" anymore - Is focused on a particular problem or situation; typically undesirable - The "3x5 Why's?" is the approach to provide direction to determine all possible causes that led to the issue occurrence. - The "3x5 Why's" Root Cause Analysis in broken down into three key areas: 1) DIRECT CAUSE: What were the immediate reason and causes that led to the nonconformity? 2) DETECTABILITY: What process controls (e.g. inspection and/or test) were in place and why was the non-conformity not caught by these controls? 3) SYSTEMIC CAUSE: What core policies, procedures, processes or overall governing systems broke down and allowed the problem to occur and go undetected?

3x5 Why Root Cause Analysis Example What does it look like? (Show picture of a completed 3x5 Why analysis - use pop carton example) When completed, the "3x5-Why?" can be very simple or can be quite involved. It all depends on the complexity of the issue. When completed, can be very simple or quite involved. It all depends on the complexity of the issue.

Defining Root Causes When investigating effects and causes: Start with a description of the process issue. May be multiple things working together, or A “chain” of events We refer to the key input issue, or issue starting the “chain of events”, as the “Root Cause” Key to success: good description of the “effect” Effect Effect Defining Root Causes When investigating causes of issues, we may find there are multiple things working together to create the outcome being studied, or there may be a “chain” of events that are happening that results in the end effect. We refer to the issue or cause with the key input having the most influence on the outcome, or issue starting the “chain of events”, as the “Root Cause”. A good key to success: start with a good description of the “effect” Cause 1 Cause 1 Cause 2 Cause 3 Cause 2 Key Cause or “Root Cause” Key Cause or “Root Cause” Cause 3

3x5 Why Root Cause Analysis When to use a “3x5 Why?”: When people do not understand the issue Need a better understanding of what is driving the issue Need to identify possible causes Need to investigate an issue quickly When is it used? When people do not truly understand the situation, or issue, or need a better understanding of what is driving the problem. To identify possible causes of a specified problem or effect Need to investigate the causes of an effect quickly

3x5 Why Root Cause Analysis When to use “3x5 Why?”: When you can answer "Yes" to these questions: 1. Do root causes of a problem need to be identified? Allows the quick identification of "why" an issue exists 2. Are there many ideas and/or opinions about the causes of a problem? People have formed opinions of the potential cause(s) Opinions may conflict or fail to identify the root cause 3. Need to know how the issue was allowed to happen? How was the issue not caught by current quality systems? What key work processes, procedures, etc. allowed the issue to be present? When you can answer "Yes" to any of these questions: 1. Do root causes of a problem need to be identified? - "3x5 Why" allows a team to quickly identify the possible "how" and "why" an issue exists 2. Are there differing ideas and/or opinions about the causes of a problem? - People closely connected to the problem being studied have formed opinions of the potential cause - These opinions may conflict or fail to identify the root cause 3. You want to understand how the issue was allowed to happen or exist? - How was the issue, or the cause of the issue, not caught by current quality (test or inspection) systems? - What key work process(es), procedures, guides/standards, etc. allowed the conditions to exist to cause the issue to be present? Using a "3x5 Why" Analysis makes it possible to quickly capture the key (root) causes of an issue for possible study Using a "3x5 Why" Analysis makes it possible to quickly capture the key (root) causes of an issue for possible study

3x5 Why Root Cause Analysis Why use “3x5 Why?”: Help prevent team from jumping to solution To encourage people to use higher order thinking skills To cut through the layers of bureaucracy to find the true reasons why an issue exists To challenge current thinking and/or paradigms To help people understand the root cause(s) of a problem To help people clarify motivation for change Why is it used To help teams prevent from jumping to solution To encourage people to use higher order thinking skills To cut through the layers of bureaucracy to find the true meaning To challenge current thinking and/or paradigms To help people understand the root cause(s) of a problem To help people clarify motivation for change

3x5 Why Root Cause Analysis Where can “3 by 5 Why?” Analysis be used: In situations requiring better understanding and/or knowledge In manufacturing, investigating part defects or production downtime In office work processes, understanding causes of issues or errors In markets or service operations, looking for causes of customer complaints With product issues or returns, looking for causes of failures or reduced performance Where is it used In any place there is a situation that requires better understanding and/or knowledge. In other words: In manufacturing, investigating part defects or downtime in production, In office work processes trying to understand the causes of issues or errors, In the market place or service operations trying to understand what is driving customer complaints, or With product issues and returns to understand what is causing a failure or reduced performance. Are there areas of issues you can think of that you can apply the “3 by 5 Whys”? Are there areas of issues you can think of that you can apply the “3 by 5 Whys”?

3x5 Why Root Cause Analysis Process How is it made Identify the problem to be studied Assess the immediate reasons (Direct Cause) why the issue occurred As applicable for the issue, assess "Why?" the issue was not detected (Detectability) Using the "Direct Cause" & "Detectability" root causes, identify the systemic cause(s) that allowed the issue to occur Develop a "Theory of Improvement" (proposed solution) from the "5-Why's?" analysis Assess the "Theory of Improvement" to ensure it will provide a sound (permanent) solution Let’s look at each step… The process for constructing and using a “3x5 Why?” Analysis is as follows Identify the problem, situation, or concept to be studied. Assess the immediate reasons why the issue occurred using the Direct Cause leg. Next, as applicable for the defect/issue occurrence, assess "Why?" the issue was not detected using the Detectability leg. Using the root causes in the "Direct Cause" and "Detectability" legs, dive deeper into identifying the associated systemic cause(s) that allowed the issue or error to occur. Develop a "Theory of Improvement" (proposed solution) from the chain of answers given to the "5-Why's?" analysis. Assess the "Theory of Improvement" to ensure it will provide the sound (permanent) solution the team, or organization, is looking for. Let’s look at each step separately…

Note: The causes will vary depending on the effect! 3x5 Why Process 1. Identify the Problem What problem (effect) needs to be improved and/or controlled? Typically described by a failure mode or undesirable event Description of the problem should be short and specific Does not contain a proposed solution! Example: Scratches or missing paint is being seen on bezel push-buttons received from supplier Enter a clear description of the observed nonconformity in the Problem Statement field. Identify the problem, situation, or concept to be studied. What problem (effect) is it that needs to be improved and/or controlled? The problem is typically described by a failure mode or undesirable condition Description of the problem should be short and specific Example: Scratches and/or missing paint on bezel push-buttons Enter a clear description of the observed nonconformity in the Problem Statement field. Please note that the causes may vary depending on the effect being studied Note: The causes will vary depending on the effect!

3x5 Why Process 2. Assess the immediate reasons why the issue occurred using the Direct Cause leg. Ask "Why?" does this condition or problem exist? Example: Why do we have scratches and missing paint on bezel push- buttons? Each time the question "Why?" is answered, ask "Why?" again Continue to ask "Why?" until all are satisfied they are at the root cause Can give insight into what containment activities can be done Often, we look for blame rather than causation – focus should be on the system, not the individual 2. Assess the immediate reasons why the issue occurred using the Direct Cause leg. - Ask "Why?" does this condition or problem exists? Example: Why do we have scratches and missing paint of bezel push-buttons? - Each time the question "Why?" is answered, ask "Why?" again. - Continue to ask "Why?" until everyone involved is satisfied they have arrived at the root cause. - This assessment can give you insight into what immediate containment activities can be done to prevent further escape of defects, or occurrence of the issue, due to this reason or root cause. Example: (need to create one) Note: Asking "Why?" five times should not be a futile effort. Refrain from using this exercise frivolously. Make sure everyone involved is making an effort to seriously answer the question "Why?". Asking "Why?" should not be a futile effort; refrain from doing this frivolously. Make sure everyone is making a serious effort to answer the question "Why?".

3x5 Why Process Step 2 Example: There can be multiple reasons (causes) why the issue exists. Start another leg if needed.

3x5 Why Process 3. Next, as applicable for the defect/issue occurrence, assess "Why?" the issue was not detected using the Detectability leg. Focus on the inspection and/or testing methods used in the work process. Again, start by asking "Why?" did we not detect this issue or error when it occurred? 3. Next, as applicable for the defect/issue occurrence, assess "Why?" the issue was not detected using the Detectability leg. Focus on the inspection and/or testing methods used in the work process. Again, start by asking "Why?" did we not detect this issue or error when it occurred? Example: (need to create one)

3x5 Why Process 4. Using the root causes in the "Direct Cause" and "Detectability" legs, dive deeper into identifying the associated systemic cause(s) that allowed the issue or error to occur. Record results in the "Systemic Cause" leg Ask "Why?" current systems didn't do the right job the first time through to provide the customer what they wanted or expected 4. Using the root causes in the "Direct Cause" and "Detectability" legs, dive deeper into identifying the associated systemic cause(s) that allowed the issue or error to occur. - Record these results in the "Systemic Cause" leg. - Ask "Why?" our current systems didn't do the right job the first time through to provide the customer what they wanted or expected? Example: (need to create one)

3x5 Why Process 5. Develop a "Theory of Improvement" (proposed solution) from the chain of answers given to the "5- Why's?" analysis. For each leg, identify corrective action needed to resolve root cause(s) Record information in Corrective Action fields on the "3x5 Why's?" Template Develop a "Theory of Improvement" (proposed solution) from the chain of answers given to the "5-Why's?" analysis. - For each leg, identify the corrective action steps needed to resolve the identified root cause. - Record this information in your team's action plan or in the Corrective Action fields to the right of the "Why?" boxes in the "3x5 Why's?" Template Example: (need to make one)

3x5 Why Process 6. Assess the "Theory of Improvement" to ensure it will provide the sound (permanent) solution the team, or organization, is looking for. Great tools to use: the "If-Then" or Force Field Analysis. When satisfied: attach completed 3x5 Why Template to 8D Task (GC02 from the GENCA task group) in the Action Request (AR) 6. Assess the "Theory of Improvement" to ensure it will provide the sound (permanent) solution the team, or organization, is looking for. - A great tool to use to follow-up on the "5-Why's?" is the "If-Then" tool or the Force Field Analysis. - When satisfied with the proposed action, attached the completed 3x5 Why Template to the 8D Task (GC02 from the GENCA task group) in the Action Request (AR). (Show completed 3x5 Why with "highlighted" actions)

3x5 Why Example A completed “3x5 Why?” Analysis may look like this: Share the example of the complete "3x5 Why" for the Scratches or Missing Paint on Bezel Push-buttons. (Create 3x5 Why using the Scratches or Missing Paint)

Multi-Leg 5 Why Example This example shows just how spread out a “5-Why” can get: Share the example of the complete "3x5 Why" for the Scratches or Missing Paint on Bezel Push-buttons. (Create 3x5 Why using the Scratches or Missing Paint)

3x5 Why Best Practices Things to Consider: Identify and verify the most likely causes If multiple root causes - consider using an Interrelationship Diagram to identify true (driving) key root causes Root causes can and should be verified Collecting data and/or information on the work process, or Perform planned experiments Causes are verified in two ways: The effect is present when the cause is present, or When the cause isn't present, the effect doesn't exist Things to consider: - Identify and verify the most likely causes - If there are multiple root causes to the issue being assessed, consider using an Interrelationship Diagram to identify to true (driving) key root causes - The identified root causes can and should be verified by collecting data, or gathering information, on the work process, or by performing planned experiments - Causes are verified in two ways: 1) the effect is present when the cause is present, or 2) when the cause isn't present, the effect doesn't exist - Note that multiple causes can produce the same effect, or that a root cause can produce multiple effects - Also, when you have multiple causes, consider which causes are occurring the most (frequency and/or downtime), or having the biggest impact ($ loss), assess them using a Pareto diagram; take action first on the 20% that are causing 80% of the effect. - The greatest success in improvements is achieved by identifying, verifying, and removing those causes that contribute the most to producing the effect

3x5 Why Best Practices Things to Consider (con’t): Note: multiple causes can produce the same effect, or A root cause can produce multiple effects If multiple causes: Consider which causes are occurring the most (frequency and/or downtime), or having the biggest impact ($ loss), Assess them using a Pareto diagram; take action first on the Top 20% that are causing 80% of the effect The greatest success in improvement is achieved by identifying, verifying, and removing those causes that contribute the most to producing the effect Things to consider: - Identify and verify the most likely causes - If there are multiple root causes to the issue being assessed, consider using an Interrelationship Diagram to identify to true (driving) key root causes - The identified root causes can and should be verified by collecting data, or gathering information, on the work process, or by performing planned experiments - Causes are verified in two ways: 1) the effect is present when the cause is present, or 2) when the cause isn't present, the effect doesn't exist - Note that multiple causes can produce the same effect, or that a root cause can produce multiple effects - Also, when you have multiple causes, consider which causes are occurring the most (frequency and/or downtime), or having the biggest impact ($ loss), assess them using a Pareto diagram; take action first on the 20% that are causing 80% of the effect. - The greatest success in improvements is achieved by identifying, verifying, and removing those causes that contribute the most to producing the effect

3x5 Why Best Practices Getting the most out of your “3x5 Why?” Analysis: Pull together a good cross-functional team (4-8 people): people from the process, a subject matter expert, a supplier, the customer or customer representative, and someone “fresh” to the process You can always do more than five whys, but try not to do less than five DO "all three legs": Direct Cause, Detectability, Systemic Cause 1st-pass: defining the immediate root cause 2nd-pass: understanding why inspection/test methods did not work 3rd-pass: what Systemic weakness or breakdown allowed the problem to occur Getting the most out of your "3x5 Why?" Analysis Pull together a good cross-functional team (4-8 people): people from the process, a subject matter expert, a supplier, the customer or customer representative, and someone “fresh” to the process You can always do more than five whys, but try not to do less than five DO "all three legs": Direct Cause, Detectability, Systemic Cause 1st-pass: defining the immediate root cause 2nd-pass: understanding why inspection/test methods did not work 3rd-pass: what Systemic weakness or breakdown allowed the problem to occur

3x5 Why Best Practices Getting the most (con’t): Just like the C&E Diagram, "3x5 Why's?" can be carried out on many levels Primary analysis is done to find the most likely cause Use this most likely cause for the effect (or problem statement) for next level "3x5 Why?" Analysis Mental blocks can occur when searching for root causes When this happens, “walk the process” to look for possible causes Keep in mind: the more levels - the better the results The true root causes may be hidden several levels below the more easily identified causes Follow each use of the tool with a debriefing session Allow individuals the chance to share their learning’s with others Getting the most out of your "3x5 Why?" Analysis Just like the C&E Diagram, "3x5 Why's?" can be carried out on many levels Primary analysis is done to find the most likely cause Use this most likely cause for the effect (or problem statement) for next level "3x5 Why?" Analysis Mental blocks can occur when searching for root causes When this happens, “walk the process” to look for possible causes Keep in mind: the more levels - the better the results The true root causes may be hidden several levels below the more easily identified causes Follow each use of the tool with a debriefing session Allow individuals the chance to share their learning’s with others

3x5 Why Root Cause Analysis Summary A “3x5 Why’s?” Analysis is: The most basic form of Root Cause Analysis Focused on a particular undesirable problem or effect An approach to determine all possible causes that lead to the effect (issue) “3x5 Why’s?” Analysis helps to: Find the immediate reason (Direct Cause) for the effect Find the reason the nonconformity was not caught (Detectability) Find the reason system allowed problem to occur (Systemic Cause) Determine the best course of action to resolve the issue In Summary: A “3x5 Why’s?” Analysis is: The most basic form of Root Cause Analysis Focused on a particular undesirable problem or effect An approach to determine all possible causes that lead to the effect (issue) “3x5 Why’s?” Analysis helps to: Find the immediate reason (Direct Cause) for the effect Find the reason the nonconformity was not caught (Detectability) Find the reason system allowed problem to occur (Systemic Cause) Determine the best course of action to resolve the issue

Thank You To learn more about Root Cause Analysis or other Quality Tools, contact: Iowa Quality Center 3375 Armar Drive Marion, Iowa 52302 (319) 398-7101 www.iowaqc.org On Facebook at: Iowa Quality Center