Invented in the 1930’s by Toyota Founder Kiichiro Toyoda’s father Sakichi and made popular in the 1970s by the Toyota Production System, the 5 Whys strategy involves looking at any problem and asking: “Why?” and “What caused this problem?”

1. Fish Bone
Analysis
MPA 208 Planning Workshop

2. Fish Bone Diagram

3. Definition of 5 Whys
Invented in the 1930’s by Toyota Founder
Kiichiro Toyoda’s father Sakichi and made
popular in the 1970s by the Toyota Production
System, the 5 Whys strategy involves looking
at any problem and asking: “Why?” and
“What caused this problem?”

4. Understanding how to use
the 5-Whys for Root Cause
Analysis. The 5-Why method of
root cause analysis requires you
to question how the sequential
causes of a failure event arose
and identify the cause-effect
failure path. ‘Why’ is asked to
find each preceding trigger until
we supposedly arrive at the root
cause of the incident.
Unfortunately it is easy to arrive
at the wrong conclusion.
A Why question can be answered with multiple answers, and unless there is
evidence that indicates which answer is right, you will most likely have the
wrong failure path. You can improve your odds of using the 5-Why method
correctly if you adopt some simple rules and practices

5. The idea is simple. By asking the question "Why"
you can separate the symptoms from the causes
of a problem. This is critical as symptoms often
mask the causes of problems. As with effective
incident classification, basing actions on
symptoms is worst possible practice. Using the
technique effectively will define the root cause of
any non-conformances and subsequently lead
you to defining effective long term corrective
actions.
http://www.imsworld.org accessed Feb 14, 2014

6. 1. Assemble a team of people knowledgeable about the area of non-
conformance. Include as many personnel as possible.
2. On a flip chart, presentation board, or even paper; write out a description of
what you know about the problem. Try to document the Problem and
describe it as completely as possible. Refine the definition with the team.
Come to an agreement on the definition of the Problem at hand.
3. Have the team members ask “Why” the Problem as described could occur,
and write the answer down underneath the Problem description.
4. If the answer provided from 3 (above) does not solve the Problem, you must
repeat steps 3 and 4 until you do.
5. If the answer provided from 3 (above) seems likely to solve the Problem,
make sure the team agrees and attempt a resolution using the answer. You
may find that there are more than one root causes to the problem
How to Use the 5 Whys ?

7. Non-Conformance
Components are being delivered late to our customers.
• Why 1
Why were we unable to meet the agreed-upon timeline or
schedule for delivery? The job took much longer than we
thought it would.
• Why 2
Why did it take so much longer? Because we under estimated
the complexity of the job.

8. • Why 3
Why did we underestimate the complexity of the job?
Because we made a quick estimate of the time
needed to complete it, and did not list the individual
stages needed to complete the project.
• Why 4
Why didn't we do this? Because we were running
behind on other projects.
• Why 5 and Root Cause
Why are we running behind on other projects? We do
not allow enough manufacturing/lead time when

9. 5 why analysis

11. Root Cause Analysis
Root cause analysis is a combination of the art
and science used to find the underlying
reasons for a given effect. One of the most
widely used root cause analysis tools is the 5
Whys. It is a simple, effective method of
problem solving that can help teams identify
and eliminate the root cause of a problem.

12. is an approach for identifying
the underlying causes of why
an incident occurred so that
the most effective solutions
can be identified and
implemented. It's typically
used when something goes
badly, but can also be used
when something goes
well. Within an organization,
problem solving, incident
investigation and root cause
analysis are all fundamentally
connected by three basic
questions: What's the
problem? Why did it happen?
and What will be done to
prevent it

13. A Root Cause Analysis (RCA) is a process for
identifying the basic or causal factors that
underlie variations in outcomes. An RCA
typically allows you to identify the “root” of
the problem in a process, including how,
where, and why a problem, adverse event, or
trend exists. This analysis should focus on a
process that has potential for redesign to
reduce risk. The RCA is also a way of looking at
unexpected events and outcomes to
determine all of the underlying causes of the
event and identify recommended changes
that are likely to improve them. Through an
RCA, you can make decisions and look for
sustainable solutions based on data and facts.
Remember that active failures are rarely root
causes; rather, latent conditions over which
we have control are often the root cause of a
problem. An RCA focuses primarily on systems
and processes, not individual performance.

14. • Determine the primary cause(s) and
contributing factors. An RCA is generally
broken down into the following steps:
• Collect data
• Analyze data
• Develop and evaluate corrective actions, using
PDSA cycle
• Implement successful corrective actions

15. Plan-Do-Study-Act Cycle
W Edwards Deming is most famous for Deming
PDCA Cycle, otherwise known as the Shewhart
cycle, or the Deming Wheel's “Plan-Do-Check-
Act” (modified to “Plan-Do-Study-Act”). The
PDSA cycle is a basic and scientific method for
improvement.
Once a team has mapped a process, set a goal,
developed measures and a data collection plan
and selected changes, the next step is to test
those small changes using the PDSA cycle. It's a
quick way to improve work processes that
allows teams to rapidly test a change on a
small scale. Risk taking is encouraged and
failures are OK because the team learns from
them.
The PDSA cycle brings data, learning, and
action together into one process. It should be
noted that improvement often requires
multiple PDSA cycles.

19. Paretho
Using the 80:20 Rule to Prioritize
Imagine that you've just stepped into a new role as head of
department. Unsurprisingly, you've inherited a whole host of
problems that need your attention. Ideally, you want to focus
your attention on fixing the most important problems. But
how do you decide which problems you need to deal with
first? And are some problems caused by the same underlying
issue?
Pareto Analysis is a simple technique for prioritizing possible
changes by identifying the problems that will be resolved by
making these changes. By using this approach, you can
prioritize the individual changes that will most improve the
situation.

20. Pareto Analysis uses the Pareto Principle – also
known as the "80/20 Rule" – which is the idea
that 20% of causes generate 80% of results.
With this tool, we're trying to find the 20% of
work that will generate 80% of the results that
doing all of the work would deliver.
Note: The figures 80 and 20 are illustrative – the Pareto
Principle illustrates the lack of symmetry that often
appears between work put in and results achieved.
For example, 13% of work could generate 87% of
returns. Or 70% of problems could be resolved by
dealing with 30% of the causes.

21. How to Use the Tool
Step 1: Identify and List Problems – First, write a list of all of the problems that you
need to resolve. Where possible, talk to clients and team members to get their
input, and draw on surveys, helpdesk logs and suchlike, where these are available.
Step 2: Identify the Root Cause of Each Problem – For each problem, identify its
fundamental cause. (Techniques such as Brainstorming, the 5 Whys, Cause and
Effect Analysis, and Root Cause Analysis will help with this.)
Step 3: Score Problems – Now you need to score each problem. The scoring method
you use depends on the sort of problem you're trying to solve. For example, if
you're trying to improve profits, you might score problems on the basis of how
much they are costing you. Alternatively, if you're trying to improve customer
satisfaction, you might score them on the basis of the number of complaints
eliminated by solving the problem.

22. Step 4: Group Problems Together By Root Cause – Next, group problems together by
cause. For example, if three of your problems are caused by lack of staff, put these
in the same group
Step 5: Add up the Scores for Each Group – You can now add up the scores for each
cause group. The group with the top score is your highest priority, and the group
with the lowest score is your lowest priority.
Step 6: Take Action – Now you need to deal with the causes of your problems, dealing
with your top-priority problem or group of problems first. Keep in mind that low
scoring problems may not be worth bothering with; solving these problems may
cost you more than the solutions are worth.
Note: While this approach is great for identifying the most important root cause to
deal with, it doesn't take into account the cost of doing so. Where costs are
significant, you'll need to use techniques such as Cost/Benefit Analysis, and use
IRRs and NPVs to determine which changes you should implement

24. http://depts.washington.edu/oei/resources/toolsTemplates/pareto_principle.pdf