5 Why Analysis

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Is the powerful question… own it!!
2
 When

SUPPLIER : Customer:
8D
REPORT
Concern title : Customer Reject n° Open Date :

Status Date App Part Name:

licat Part No:
ion: ReleaseLevel:
Plan Release Date:
t:

1. Team: 2. Problem Description

Investigation:

3. Containment Actions: % Effect: Implementation

Date:

4. Root Causes : % Contribution :

5. Chosen permanent Corrective Verification : % Effect:

Actions:

6. Implemented Permanent Corrective Actions Implementation

Date:

7. Actions To Prevent Recurrence: Implementation

Date:

8. Congratulate Your Team: Close date: Reported By:

Name :
Dept:
Tel:

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 QUALITY IMPROVEMENT
Structured Problem Solving & Root Cause Analysis

Zero
Plan Do Check Act Defect

Culture

Zero
Plan Do Check Act Defect

Culture

4
 Structured Problem Solving Process Definitions

 DEFINITIONS:
– PROBLEM - A variation or gap between the actual situation and the standard or
desired future state
– PROBLEM SOLVING PROCESS – A set of steps followed to eliminate the
variation or gap between the actual situation and the standard or desired future
situation
– TOOL – Any graphical or analytical technique that assists in the problem solving
process.

 Supplier’s 5-WHY ANALYSIS – An analysis tool used to determine and document

a problem’s root cause(s). Detailed 5-Why analysis includes separate analysis
paths for:
» Why the specific problem occurred (path 1)
» Why the quality process failed to detect the problem (path 2)
» Why the system allowed the problem to occur (path 3)
» Provides a visual representation and identifies how specific root causes
link to higher order system issues that must be corrected.

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 Structured Problem Solving Process Steps

 Delphi Problem Solving (DPS) Process – Four step common Delphi Problem Solving Process
consisting of SELECT, CONTAIN, CORRECT, and PREVENT.
» Although Suppliers do not utilize the DPS form, the structured problem solving thought
process applies and is the foundation for the completion of a 5-Why.
– SELECT - Process of identifying an existing or potential nonconformity or other undesirable situation.
This step also includes identifying a problem solving project team leader and team members, clearly
defining the problem in measurable terms, establishing a repeatable measurement method, and
setting goals for problem solving project. Zero
Plan Do Check Act Defect

Culture

– CONTAIN – Short-term actions taken to protect the customer from receiving nonconforming materials
or services.
– CORRECT – Actions taken to analyze and eliminate the causes of an existing nonconformity or other
Zero
undesirable situations. Defect
Plan Do Check Act

Culture

– PREVENT – Actions taken to control and standardize the process to prevent recurrence.
Zero
Plan Do Check Act Defect

Culture

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 Problem Solving Tools

 Analyze Data
Pareto Chart Histogram
Brainstorming
Control Chart Process Capability
PFD
Check Sheet Fishbone diagram
PFMEA

5 Why Analysis

 Charts can be used for different purposes in various stages of the problem-solving
process

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 Power of Asking Questions

Who are the best at asking questions to

solve problems?

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 Power of Asking Questions

Children!
Why?
…because they keep asking objective, open-ended questions
until the answer is simple and clear

When working with people to solve a problem,

it is not enough to tell them what the solution is. They
need to find out and understand the solution for
themselves. You help them do this by asking open-
ended , thought provoking questions.
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 Power of Asking Questions

Target of WWWWHWH Collect all the useful information for the Problem resolution

Who is concerned ?
WHO Who has identified the problem ?
Who is the main person ?
What are the measure on the product ?
WHAT What is the problem ?
What is the frequency ?
Where did the problem occur ?
WHERE Where is the issue located on the product?
Where was the problem detected?
When did the problem occur ?
WHEN Is there a specific period ?
Is there a favourable period ?

HOW How is the concerned product manufactured ?

How many parts are concerned ?

What is the frequency ?
HOW MANY What are the measure on the product ?
How much does it cost ?

WHY
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 Power of Asking Questions
Suggestion of additional question

What is the exact defect and where in the process is it failing? Is the defect present prior to assembly or after assembly (happening
(“Don't work” is not a defect) during process or prior to process)?

Are there more than one of the same components on the assembly
and is the defect isolated to one area? This should determine if it is Is the defect present on more than one shift or isolated to one shift?
parts or equipment.

Are there other areas using the same component and are they Does the defect only occur under certain conditions, temp, humidity,
having the same problem? If yes, document dept. etc…?

Did you look at the PPAP sample, see if the same condition is on Has there been a change in the equipment recently, such as PM
the sample part? work or any type of modification?

Is the defect isolated to one lot number? Are you running parts to the current rev level, or is the stock old)?

Are you running the correct part number on your equipment or

Does the defect follow when swapped from bad part to good part?
product?

Have the parts been measured to verify they are the correct or
Is the defect cavity specific (molded parts)?
incorrect dimension?

Have the supplier representative help verify defect if applicable

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 Close-Ended vs. Open-Ended Questions

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?”

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 Benefits of Open-Ended Questions

 Requires thought
 Promotes additional research
 Enhances problem solving skills
 Does not assume there is one right answer
 Avoids predetermined answers
 Stimulates discussion
 Empowers the person answering

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

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 More Examples

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)

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.)

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)

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 The respect of the logic: Check by THEREFORE test

THEREFORE

The problem
occured
THEREFORE
(Because)
Event 1
Why occured

THEREFORE
(Because)
Event 2
Why
occured

THEREFORE
(Because)
Event 3
Why occured
THEREFORE
(Because)
Event 4
Why occured

(Because)
Event 5
Why occured =
Rootcause

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 5-Why Analysis (Paths 1 & 2)

Part # Corrective Action

Define Problem with Responsibility Date
Use this path

for the specific nonconformance being

investigated Root Causes A

W
hy d
WHY? Therefore
id w
e ha
ve t
Use this path WHY? Therefore
h e pr
oble
to investigate why the problem was not
detected

WHY? Therefore
m? B
W
WHY?

hy d
Therefore WHY? Therefore

id th A

Use this path WHY?

e pr
Therefore * Next

oble
mr
to investigate the systemic root cause

WHY?
each
Therefore

th e
cust
ome
Ref. No. (Major Disruption, PR/R…) WHY? Therefore WHY? Therefore

W r?
PRR # MD # hy did
B C

our
Date of Issue WHY? Therefore * Next

syst
Customer Supplier (if applicable) em
WHY?

allo
Therefore

w it
to o
c
Product / Process Delphi Location Systemic Root Cause Code WHY? Therefore

cu r? C

* Next

Implement
Communicate Problem Resolution System Change
Problem Resolution Complete to Customer Date: Process Change Break Point Date: Date:
Initiate Problem Resolution Date: CS2
Corrective
Action imp.
Implement Containment Date: date

Lessons Learned:

16
Error/Defect Prevention (path 1)
vs.
Error/Defect Detection (path 2)

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 Error / Defect

To optimize error proofing, it is important to clearly understand the difference between a Defect
and an Error:

– Defect: An objective imperfection, a non-conforming part, a product or deliverable that does not meet the
specification and/or stated requirement…..i.e., the “effect”.
– Error: What contributed to, or caused, the ultimate defect (sometimes known as the root cause). The
event or action that was responsible for creating the defect…..i.e., the “cause”.

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 Prevention / Detection

 There are two types of error proofing solutions;

– Prevention - To keep from happening, to counter or avert in advance
– Detection - The act of finding, discovering, or uncovering

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 Prevention / Detection
Error / Defect

The definitions of prevention and detection

apply to both errors and defects

Prevention
Prevention Detection
Detection

Error
Error Prevention
Prevention -- To
To keep
keep Error
Error Detection
Detection -- Finding
Finding or
or
the
the root
root cause
cause or
or source
source of
of discovering
discovering the
the root
root cause
cause or
or
the
the defect
defect from
from happening
happening source
source of
of the
the defect
defect

Defect
Defect Prevention
Prevention -- ToTo keep
keep Defect
Defect Detection
Detection -- Finding
Finding
the
the physical
physical result
result of
of an
an error
error or
or discovering
discovering thethe problem
problem oror
from
from happening;
happening; therefore,
therefore, aa imperfection;
imperfection; thethe physical
physical
defect
defect isis not
not created
created result
result of
of the
the error
error

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 5-Why Analysis (Path 3)

Part # Corrective Action

Define Problem with Responsibility Date
Use this path

for the specific nonconformance being

investigated Root Causes A

W
WHY? Therefore

hy d
id w
Use this path WHY? Therefore
e ha
ve t
he p
to investigate why the problem was not
detected

WHY?
r
Therefore

oble
WHY? Therefore WHY?
m? Therefore
B

W A
hy d
Use this path WHY?

id th Therefore * Next

to investigate the systemic root cause

e pr
oble
m
WHY? Therefore

reac
h th
Ref. No. (Major Disruption, PR/R…) WHY? Therefore WHY?
e cu Therefore

stom B C
PRR # MD #
W e r?
hy d
Date of Issue WHY? Therefore * Next

id o
Customer Supplier (if applicable)
u r sy WHY? Therefore

stem
allo
w it
Product / Process Delphi Location Systemic Root Cause Code WHY? Therefore

to o C

ccur * Next

Problem Resolution Complete

Communicate Problem Resolution
to Customer Date: Process Change Break Point Date:
? Implement
System Change
Date:
Initiate Problem Resolution Date: CS2
Corrective
Action imp.
Implement Containment Date: date

Lessons Learned:

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Systemic Analysis

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 Frequently Seen Systemic Problems

Operator did not

Do we stop here? follow the procedure

Does a
No
standard Create a standard
procedure procedure
exist?

Yes

…or do we get Is the No

operator Train operator
to the true trained?
systemic issue?
Yes

Was the
No
procedure Create a system to assure
followed conformity to procedures
correctly?

Yes

Yes Is the No
Do you have the right Modify procedure
person for this job/task? procedure
& check effectiveness
effective?
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 Suggestion for Systemic Root cause search

Use the Effect/ Cause diagram for Systemic root cause analysis during the 5 Why analysis

MANPOWER
METHODS MEASUREMENT
MANAGEMENT EFFECT =
• Compentcy • Worksation
PROBLEME
• Measurement devices
• Knowledge organizationl • Setting up
• Apllication • Working Instructions • Master checking
• Respect of • Stockage ...
procédures • Transport
• Involvement • Supply
• Lot size
... ...

• No Conformity to • Air control • Break down

specification • Temperature • Technology
• Dégradation • Noise control • Year old
• Wearing • Contamination • Obsolescence
• Not fitted • • Design
... ... • Repeatability
...

MOTHER NATURE
MATERIAL (ENVIRONMENT) MACHINE

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 Frequently Seen Systemic Problems

Define Problem
Do we stop here?
Carton would not
fold properly

WHY?
Use this path for
specific non- Bend strength was
conformance too high

WHY?

Score was not cut

deep enough

WHY?

Cutting tool was

worn CA: Replace the tool

WHY?
PM interval not
adequate

WHY?
PM failure; PM intervals are not
Or do we get to the strategically set based on
manufacturer’s recommendations
systemic failure? and history

CA: Fix the system

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 Frequently Seen Systemic Problems

Another example…
Define Problem

OSHA finding

WHY?
Use this path for
specific non- Rail was loose
conformance

WHY?

Rail screws were

not tight CA: Tighten screws
WHY?

No procedure to
check safety features CA: Add procedure
WHY?
No standard safety
check requirements

WHY?
Safety is not top priority of the
organization…culture sees
True systemic failure production as first priority

CA: Change the

culture 26
 Frequently Seen Systemic Problems

Another example of not getting to the systemic issue

Score was broken

Belt was
Why?
not in correct position

Why? Was adjusted to obtain

proper opening force

Fixture design was

Why?
not adequate
Hard Fix Systemic
Fix
Fixture design on this specific
Why?
equipment was not validated

Product was validated on other

Why?
similar, but not identical, equipment

No requirement for validating all

Why? potential equip - APQP
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 Systemic Root cause
Example with Plastic part

Picture of the Defect

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 Systemic Root cause
Example with Plastic part

Results of the Bran storming done for the technical root cause analysis
Caution: at this stage the 5 Why analysis is not completed

Example with Plastic

part

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 Others examples

As explained the examples shown during the session have been

removed from the Powerpoint file.

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 Consequence if no eradication of Root cause

Effects of not getting to the systemic failure

Level of Problem Corresponding Lebel of Frequency of
countermeasure countermeasure

Puddle of oil on the Clean up the floor Very Often

shopfloor
h y?
W Because the machine is Clean up the machine Very Often
leaking oil

h y? Because a O-ring is Replace the O-ring Often

W
damaged (with current design)
h y?
W We didn’t buy the Change the type of the Many trial are needed
adequate O-ring O-ring and/or the before acheiving good
supplier result
?
hy Because the O-ring Modification od O-ring ONE time
W
specifcation was not specifcation by
matching to the engineering
application
31
 Systemic action versus Symptom action

The next slide are applicable when you have realized many 5 Why
analysis with numerous Systemic weakness.

We suggest a method to move from a Symptom action plan to a

Systemic action plan

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 Systemic action versus Symptom action

Category of Systemic Quality Issue Occurrence

Standardization (i.e. work instructions, quality reaction plan, look across, process and quality 29 percent
control plan, etc.)

APQP (i.e. misunderstanding customer needs, quality pass through, incomplete APQP, etc.) 25 percent
 

Hidden Factory (i.e. defining rework, incorporation into the standard work plan, other processes 14 percent
not documented, etc.) NOTE: Should work to reduce/eliminate rework, since this is reactive (not  
proactive).

FMEA (i.e. incompletion, not transferring work to work standard and practice; incorrect risk taking, 13 percent
etc.)

Tiered supplier management (i.e. APQP, supplier quality, etc.) 11 percent

Operator training (i.e. insufficient regular training, certified worker, etc.) 8 percent

Maintenance programs (i.e. lack of proactive maintenance, delayed reactive maintenance) 5 percent

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 Systemic action versus Symptom action

Are we prioritizing by SYMPTOMS…

Top Issues
120

Occurrence (Qty)
100
80
60
40
20
0
Incorrect Bar Code Late Delivery Mixed Parts Damaged
Coating Will Not Parts
Read

…or by SYSTEMIC issues?

Top SYSTEMIC Issues
Systemic Issues
Lack of No 140
Issue Qty Not Carton
Setup Standard 120
Following Design
Standard- APQP 100
Procedure Inadequate
ization Process 80
Incorrect Coating 100 X 60
Bar Code Will Not Read 50 X 40
20
Late Delivery 40 X
0
Mixed Parts 30 X X
Lack of Setup No Standard Not Following Carton Design
Damaged Parts 10 X Standard- APQP Process Procedure Inadequate
ization

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 Systemic Problems & Tools

Suggested Tool Selection

Systemic Category Line First Value Total

Layered Look- Customer Plant
5-Why Side Time Stream Pareto Productive
Audit Across Visit Visit
Review Quality Mapping Maintenance

Standardization X X X X X X X X

APQP X X X X X X X

"Hidden Factory" X X X X X

FMEA X X X X X X X

Tiered supplier managementX X X X X X X X X

Operator training X X X

Maintenance X X X X X X
X

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 5-Why Analysis
(Corrective Action)
Corrective Action
with Responsibility Date
Define Problem
Use this path for
the specific A
nonconformance Root Causes
being investigated

W
hy d
WHY?
id w
e ha
ve t
Use this path to WHY?
he p
investigate why the
problem was not r oble
detected.
WHY? m? B

W
WHY? hy d WHY? Corrective Action:
id th
e pr A

WHY? oble Implement, Validate,

Use this path to
investigate the m reac
systemic root cause
h th and Ensure Ongoing
WHY?
e cu
stom Compliance to processes
W e r? C
and procedures
Ref. No. (Spill, PR/R…) WHY?
hy did
WHY?

our B

Date of Spill WHY? syst

em allo
w it
Customer WHY?
to o
c c u r?
Product / Process Delphi Location Content Latest Rev Date WHY?

Problem Resolution Complete Communicate to Customer Date: Process Change Break Point Date: Implement System Change Date:

Lessons Learned:

36
 5-Why Analysis
Conclusions

If we consiser the diagram and the 2 objectives below ….

MANPOWER
MANAGEMENT METHODS MEASUREMENT

Objective 1: Do a good part, the ? ? ?

first time and everytime

Objective 2 : ZERO Defect at

Customer ? ? ?

MOTHER NATURE
MATERIAL (ENVIRONMENT) MACHINE

… then what is the responsabilty of the Management in the achievement

of the objectives
Do your own assessment.

37
 5-Why Analysis
(US Railroad gauge story)

U. S. Standard Railroad Gauge

The U. S. standard railroad gauge (width between the two rails) is 4 feet, 8.5 inches. One might say that's an exceedingly odd
number.
Why was that gauge used? Because that's the way they built them in England, and English expatriates built the US railroads.
Why did the English build them like that? Because the first rail lines were built by the same people who built the pre-railroad
tramways, and that's the gauge they used? Why was that gauge used? Because the people who built the tramways used the same
jigs and tools that they used for building wagons, which used that wheel spacing.
So! Why did the wagons have that particular odd wheel spacing? Well, if they tried to use any other spacing, the wagon wheels
would break on some of the old, long distance roads in England, because that's the spacing of the wheel ruts.
Who built those old rutted roads? Imperial Rome built the first long distance roads in Europe (including England) for the Legions.
The roads have been used ever since. What do we know about the ruts in the roads? Roman war chariots formed the initial ruts,
which everyone else had to match for fear of destroying their wagon wheels. Since the chariots were made for (or by) Imperial
Rome, they were all alike in the matter of wheel spacing.
There you have it! The United States standard railroad gauge of 4 feet, 8.5 inches derives from the original specification for an
Imperial Roman war chariot. Specifications and bureaucracies live forever. So the next time you are handed a specification and
wonder what horse's rear came up with it, you may be exactly right, because the Imperial Roman war chariots were made just wide
enough to accommodate the back ends of two warhorses.
There's an interesting extension to the story about railroad gauges and horses' behinds. When we see Space Shuttle Columbia sitting
on its launch pad, there are two big booster rockets attached to the sides of the main fuel tank. These are solid rocket boosters, or
"SRB's". Thiokol makes the SRB’s at their factory at Utah. The engineers who designed the SRB's might have preferred to make
them a bit fatter, but the SRB's had to be shipped by train from the factory to the launch site because of their size and weight. The
railroad line from the factory has to run through a tunnel in the mountains, and the SRB's had to fit through that tunnel. The tunnel is
slightly wider than the railroad track, and the railroad track is about as wide as two horses' behinds.
So, the major design feature of what is arguably the world's most advanced transportation system was determined over two thousand
years ago by the width of a horse's rear end!

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