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

3375 Armar Drive

Marion, Iowa 52302
319-398-7101
www.iowaqc.org

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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

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3x5 Why Root Cause Analysis

What is it?
The 5 Whys? is the most basic form of Root Cause Analysis
Simple: Ask why? until you cant ask why? anymore
Focused on a particular problem or effect: typically undesirable
3x5 Whys?: an approach to determine all possible causes
that lead to the effect (issue)
Broken down into three key areas:
1. Direct Cause: The Immediate reason for the effect
2. Detectability: Reason nonconformity was not caught
3. Systemic Cause: Reason system allowed problem to occur

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3x5 Why Root Cause Analysis Example

When completed, can be very simple or quite involved.

It all depends on the complexity of the issue.
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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
Cause 1

Cause 1

Cause 2

Key Cause or
Root Cause

Cause 3

Cause 2

Key Cause or
Root Cause
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Cause 3
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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

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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?

Using a "3x5 Why" Analysis makes it possible to quickly

capture the key (root) causes of an issue for possible study
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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

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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

Are there areas of issues you can think of

that you can apply the 3 by 5 Whys?
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3x5 Why Root Cause Analysis Process

How is it made
1. Identify the problem to be studied
2. Assess the immediate reasons (Direct Cause) why the issue
occurred
3. As applicable for the issue, assess "Why?" the issue was not
detected (Detectability)
4. Using the "Direct Cause" & "Detectability" root causes, identify
the systemic cause(s) that allowed the issue to occur
5. Develop a "Theory of Improvement" (proposed solution) from
the "5-Why's?" analysis
6. Assess the "Theory of Improvement" to ensure it will provide a
sound (permanent) solution
Lets look at each step
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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.

Note: The causes will vary depending on the effect!

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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 pushbuttons?

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
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?".
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3x5 Why Process

Step 2 Example:

There can be multiple reasons (causes) why the issue exists.

Start another leg if needed.
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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?

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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

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3x5 Why Process

5. Develop a "Theory of Improvement" (proposed
solution) from the chain of answers given to the "5Why'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

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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)

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3x5 Why Example

A completed 3x5 Why? Analysis may look like this:

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Multi-Leg 5 Why Example

This example shows just how spread out a 5-Why can get:

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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:

1. The effect is present when the cause is present, or
2. When the cause isn't present, the effect doesn't exist

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3x5 Why Best Practices

Things to Consider (cont):
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

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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

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3x5 Why Best Practices

Getting the most (cont):
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 learnings with others

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3x5 Why Root Cause Analysis Summary

A

3x5 Whys? 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 Whys? Analysis helps to:

1. Find the immediate reason (Direct Cause) for the effect
2. Find the reason the nonconformity was not caught
(Detectability)
3. Find the reason system allowed problem to occur (Systemic
Cause)
4. Determine the best course of action to resolve the issue

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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

2014 Rockwell Collins.

All rights reserved.

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