Complex 5-Why’s – the #3 Post of 2010

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We continue to look at the top posts on the Lean Leadership blog from 2010. Complex 5-Why’s originally ran in November of last year and came in at #3.


[tweetmeme]Our Production Manager, John, is heading out to the production floor.  He sees that his highest priority line is down again.  “What is it this time?” he asks.  His top mechanic replies, “I can’t believe we are down for a conveyor.  We’ll be back up before long, if we have the right sprocket.”

John decides to do a 5 Why analysis even though this appears to be a simple fix.  In the old days they might have been satisfied with replacing the sprocket.  Today, John wants to make sure that the replacement does not fail prematurely.  He wants to address the root cause.

We have already looked at simple 5 Why’s.  Several readers commented that many real life examples are not that simple and do not have straight-line answers.  Today we’ll look at a complex, multiple path 5 Why.

Complex 5 Why Root Cause Analysis

You will still go through the same basic 7 Steps of an Effective 5 Why as addressed in a previous post.  The difference with the Multiple Path 5 Why is that there will be more than one answer to some or all of the why’s.  My suggestion is that you only include the answers that you believe are contributing to the issue.  The 5 Why can spin out of control and become too complex if you include every conceivable possibility.  If you are unsure, you can capture the idea and verify if the condition exists.  For example, if someone says, “maybe the bearings have not been properly lubricated.”  Capture the idea and verify the condition of the bearing.  If the bearing hasn’t been lubricated properly, include it in your Root Cause Analysis.  There are situations where you may want to include all options which we’ll discuss next time.  Today, we will only include the conditions that we believe exist.  Let’s look at the sprocket and do a thorough Root Cause Analysis (RCA):

Problem Statement:  Conveyor stops due to a broken sprocket

5 Why - Sprocket Failure

Why #1:  Why did the sprocket break?

Answer:  [a] excessive stress [b] wrong sprocket

Why 2a:  Why is there excessive stress?

Answer:  [1] dirty conveyor [2] worn bearings [3] line speed exceeds conveyor design

Why 2b:  Why is the wrong sprocket on the conveyor?

Answer:   Correct sprocket was not in stock when replaced last time.

Root Causes & Countermeasures

Why 3a [1]:  Why is the conveyor dirty?

Answer:  Not on cleaning schedule

Why 3a [2]:  Why are there worn bearings?

Answer:  Bearings have not been PM’d

Why 3a [3]:  Why isn’t the conveyor designed for the actual line speed?

Answer:  Conveyor was taken from the bone yard to finish an in-house line modification

Why 3b:  Why wasn’t the right sprocket in stock?

Answer:  Inaccurate inventory

Why 4a [1]:  Why isn’t the conveyor on the cleaning schedule?

Answer:  New conveyor was not added to the cleaning schedule

Why 4a [2]:  Why haven’t the bearings been PM’d?

Answer:  Mechanic didn’t know about these bearings

Why 4a [3]:  Why was the conveyor taken from the bone yard?

Answer:  Management/Engineering decision to manage the cost of the project

Why 4b:  Why wasn’t the inventory accurate?

Answer:  [1] parts usage is not consistently documented [2] parts inventory is overdue

Why 5a [1]:  Why weren’t the new conveyors added to the cleaning schedule

Answer:  Early management failure

Countermeasure:  Add sanitation requirements to the project management checklist.  Update the sanitation schedule to reflect the new conveyor.

Why 5a [2]:  Why didn’t the mechanic know about the bearings?

Answer:  [2.1] New mechanic that is unfamiliar with the line changes  [2.2] Conveyor section pulled from the bone yard was not added to the PM system

Why 6a [2.1] Why wasn’t the new mechanic familiar?

Answer:  See 5a [2.2]

Why 6a [2.2]:  Why wasn’t this section of conveyor added to the PM system?

Answer:  PM’s had already been updated when the decision was made to use conveyor from the bone yard.

Countermeasure:  Modify the post project review procedure.  Changes to reflect the need for full analysis of the impact of project changes on Safety, Sanitation, PM’s, etc.  Update the PM’s to include the new conveyor.

Why 5b [1]:  Why isn’t parts usage documented properly?

Answer:  No system when the parts clerk is not on site.

Countermeasure:  Implement parts usage form to be used on all shifts.  Order sprockets as needed to re-establish minimum quantities.

Why 5b [2]:  Why is the parts inventory overdue?

Answer:  Overtime production prevented completing as scheduled.

Countermeasure:  Schedule parts inventory as soon as possible.

John and his team have invested much more time performing a thorough RCA than if they had just replaced the sprocket.  You can see though that the team has been able to identify several root causes that need to be addressed.  What would happen if they did not address these root causes?  They would likely have another premature sprocket failure.  This premature failure would be the result of the same conditions that led to the first failure.

[tweetmeme]The great John Wooden said, “If you don’t have time to do it right, when will you have time to do it over?”  If you don’t have the time to address the root causes now, you will likely be dealing with the same issues again.  What issue is your plant facing today that warrants a good 5 Why Root Cause Analysis?


The top 2 posts for 2010 will be coming soon.  #4 through #10 are below:

4.  Change Management and the Pareto Principle

5.  What Could Be Easier?  The 4 Step Deming Cycle

6.  Lean Goal Setting

7.  Launching 5S – The Pre-Audit

8.  The Hardest of the 5S’s – Sustain

9.  Simple 5-Why’s

10. Implementing Change

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About Christian Paulsen

Christian Paulsen is an Executive Consultant with 20 years of Lean Manufacturing. Chris adds value to organizations by driving process improvement and bottom line savings. Chris intends to help others by sharing the lessons learned after a quarter century of operational leadership, marriage, parenting, and even longer as a Cubs fan. Your comments on this blog are welcome. You can also connect with Chris via LinnkedIn, Twitter, and Facebook in the right sidebar. Chris welcomes your comments. Christian's professional services are available by contacting him through LinkedIn (right side bar)
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3 Responses to Complex 5-Why’s – the #3 Post of 2010

  1. Govin says:

    Hi Paul

    Congratulations on the outset for Starting Paulsen & Paulsen.

    I have been reading all your posts. The contents are very useful and the language used (with pictorial representations) are easy to understand.

    Wishing all success for Paulsen & Paulsen.


  2. Pingback: Tweets that mention Complex 5-Why’s – the #3 Post of 2010 | Lean Leadership --

  3. Venkatasubramanian S says:

    Hello Paul,

    An excellent note on RCA written in easy to understand language. And finally capped with great quote from John Wooden.

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