Sakichi Toyoda created the 5 Why’s as a technique to identify root causes of defects in manufacturing and production.
The example used in Wikipedia illustrates how that works:
The vehicle will not start. (the problem)
- Why?- The battery is dead. (First why)
- Why?- The alternator is not functioning. (Second why)
- Why?- The alternator belt has broken. (Third why)
- Why?- The alternator belt was well beyond its useful service life and not replaced. (Fourth why)
- Why?- The vehicle was not maintained according to the recommended service schedule. (Fifth why, a root cause)
What happens if we ask a sixth why? i.e. Why was the vehicle not maintained according to the recommended service schedule? Do we get to a deeper more useful root cause?
What if the answer was “They were too busy with other priorities”?
We could ask another Why. “Because they were too scared to push back on the other priorities and took an often-used shortcut, letting the alternator service go until next time.”
So, fear and habits were the real root causes, and perhaps ignorance, not knowing how to push back effectively, or manage time better.
Now we are getting closer to the only real root causes when it comes to human activity or involvement.
I assert we can do root cause analysis much more effectively and rapidly if we began with the question.
“Where did fear, habits and ignorance contribute to this outcome/situation/defect?”
This is because fear, habits and ignorance are the only real root human causes of defects, accidents, conflict, and undesirable outcomes or situations.
We can then determine better solutions quicker.
Those solutions will always involve courage, better practice and learning.
What do you think?
