The Five Whys

Root cause analysis (RCA) is a technique to use on any scale for identifying the actionable steps an organization can take towards solving a problem.  RCA launches an investigation into the root cause behind a problem.

Driving our search for the root cause is the logic that if the root cause had not occurred, the event would not have occurred, thus preventing recurrence.

The final stage of RCA is the action stage.  This is an organization’s opportunity to eliminate the problem, prevent recurrence, and reduce risk.

Evaluate the Investigation

Throughout the process, we should ask ourselves:

1. Are we involving the right people on the investigation team?

2. Does our investigation follow good RCA practice (i.e. evidence-based)?

3. Did we identify root causes, and if not, why?

4. Did we communicate our findings effectively?

Examples of RCA

Adapting an observable technique to the optimization processes, Taiichi Ohno, former executive vice president of the Toyota Motor Corp., revolutionized the company’s production system.  Toyota Motor Corp. is now the largest automotive corporation in the world.

To prevent the recurrences of outbreaks, RCA in the food industry facilitates a careful examination of foodborne illness events, paving the way for such policies as the 2005 Sanitary Food Transportation Act (Pew, 2020).

The Five Whys

The five whys is a process of getting to the root cause of a problem with five iterations of asking “why?”.  A technique rooted in observation, the five whys urges us to go beyond our initial conclusion for a solution.  This is the first step towards root cause analysis.

Problem framing becomes the next challenge. Problem framing is a method of evaluating, reframing, and stating a problem.  It is a collaborative process which works towards identifying, understanding, and prioritizing challenges, while embracing opportunities for change.

Using the scenario of a candy company receiving customer complaints of incomplete, misprinted, and missing messages plaguing the popular Valentine’s Day treat, candy conversation hearts, we can outline the process in action.

We reach our reframed problem: The budget did not accommodate sufficient training time.

Conclusion

Comparing our reframed problem with the timeline of events, we can pinpoint the time of the root cause to be when the manufacturing engineer was replaced.

We can conclude that insufficient training due to budget restraints is the root cause of the Conversation Heart message problem.

Recommendations

• Further analysis on resource allocation to understand budget restraints. 

• Collaboration of human resources and shift managers to outline training solutions.

• Training must not be a burden to employees as they accomplish their daily tasks.

• 100% incident reporting - Anonymous incident reporting in an environment free from fear of reprimand.