Diving deeper:

6 steps beyond the 5 Whys

Introduction
When an incident or accident occurs at your workplace, what do you do to fix the problem? The 5 Whys process is a common method to identify causes of the incident. But what do you do if this technique only presents further symptoms rather than the real root causes? This eBook presents a useful method for taking the analysis further than the 5 Whys process. The 6 steps beyond the 5 Whys presents a logical framework for getting to the bottom of any incident or accident in your workplace.

The 5 Whys process

At a mine site in far north Queensland, a freight train sits idle on the track. For some reason, the train cannot be loaded with its coal, and is causing a costly stoppage at the mine facility. The mine operator needs to know whats stopping the normal loading procedure.

A starting point might be to run with the 5 Whys process, whereby you start asking questions typically, at least 5 about what happened.
Why cant the train be loaded? Because the loading conveyor belt has stopped. Why has the loading conveyor stopped? Because the drive motor on the conveyor pulley has tripped out. Why has the drive motor tripped out? Because there was an overload on the drive motor. Why was there an overload on the drive motor? Because the main bearing had seized. Why has the main bearing seized? Because there was no lubrication in the bearing.

By asking 5 simple questions, the mine operator arrives at a tangible solution: ensuring that bearings in the drive motor are adequately lubricated. As this simple example demonstrates, the 5 Whys process could potentially be sufficient as a simple form of root cause analysis, with no further investigation needed. Yet, while investigators could use the 5 Whys process as a starting point, they may however soon see the need to take the investigation further.

A good first analysis but is it enough?

In some cases the 5 Whys linear nature can cause people to jump to conclusions and fail to arrive at the true cause or causes of an incident or accident. While the 5 Whys technique can be successfully used for very basic investigations, it does have a few limitations which any investigator should be aware of before using it. The limitations of the 5 Whys process include: Tendency to stop at symptoms rather than finding lower level root causes Inability to go beyond the investigators current knowledge you cant find causes for things you dont already know Lack of support to help the investigator to ask the right why questions Results arent repeatable different people often come up with different causes for the same problem Branching can occur indicating that a more in-depth analysis is needed to get to the root cause

Given that the 5 Whys process may not be enough, what follows? What should an investigator do when a more thorough, structured investigation is needed?

6 steps beyond the 5 Whys

If the 5 Whys process does not deliver the right answers, then it would be pertinent to enact the following 6 steps for a more rigorous investigation of the incident or accident. Try to do this as soon as possible, particularly step one.

Collect more information

Assemble the team

Conduct the RCA

Implement the solution (corrective actions)

Measure the success of the corrective actions

Advertise your successes

Collect more information

Collect more information

Without the right information, assumptions and guesswork can lead you astray in your understanding of a problem and will deliver no certainty in the outcomes of corrective actions.

To really understand a problem, you need plenty of evidence. And you need it as soon as possible. As soon you identify that the 5 Whys process is not sufficient to resolve an incident, you should trigger an urgent search for more information. This becomes the first step beyond the 5 Whys. Assign a person to the task of collecting as much information relating to the incident as possible. Put simply, the more information you have, the better off youll be. By acting quickly, the quality and quantity of the information you collect will be more consistent. A delay of hours or, even worse, days will negatively impact on the quality of the information you gather, and hence the subsequent analysis could be hindered.

Collect more information

Protect your information by cordoning off an area. Dont allow people to touch or interfere with important evidence. Get statements from everyone who saw or had anything to do with the problem. A delay in gathering statements allows people to think about and rationalise what they saw. The information in the statements will subsequently change and people will be hard pressed to stick to the facts or be able to recognise the changes that have been made from what they originally saw.

Top tips
Act quickly to gather as much information as you can The more evidence you can collect, the better Assign one person to the job of collecting evidence Dont throw evidence away when cleaning up after an incident make sure you save it!

Assemble the team

Assemble the team

The team may need to be available for a significant period of time so youll need the backing of management.

Get the right people together people with the knowledge and experience to help you understand the problem. Assembling the team may take a few days or longer, but it is important. Without the right people, your investigation will lack the specific detail you need resulting in a more generic report, which resembles a Failure Modes Effects Analysis (FMEA) that lists all possible causes with no real insight into the root causes. With the right people on board, your analysis will dive sufficiently deep to arrive at a workable solution. So who do you need to get? You want people who bring experience across different yet relevant job roles and people who have direct knowledge of the incident. Pick people with open minds who are willing to listen, to contribute and will help the investigation. These people should possess specific, relevant understanding of the issue - which will help you to arrive at a specific solution.

Assemble the team

Assign a skilled and experienced facilitator who is adept at controlling a group and keeping the investigation on track without bias. Be wary of appointing a subject matter expert as they may steer the group in a particular direction and who is going to argue with the subject matter expert?

Top tips
Get management support to bring the people you need to the team, for as long as is needed Appoint a skilled and experienced facilitator The number of people should reflect the complexity of the incident You may need an independent expert to join the team

Conduct the Root Cause Analysis

Conduct the Root Cause Analysis

During the RCA, the facilitator should be inclusive, ask all the questions that need to be asked, and pursue all causal pathways to their logical conclusions

Your goal is to conduct the RCA as soon as possible after the incident or accident occurs so that the information is still fresh in peoples minds and remains untainted. Appoint a time and place for the investigation to occur, as soon as the required group can be convened. Then, once the group meets, set basic ground rules around respecting others opinions and encouraging an open dialogue. The first task in an RCA is to define the problem. Add context to the problem by including information about when and where it happened, and clearly articulate the significance of the problem. This will determine the time and resources allocated to resolving it and is an important beginning. At the end of the day it will also constitute your business case that you present to management for endorsement of your recommendations. Then, create your cause and effect chart. Collect information from all the people in the room and organise it logically according to the process that you are using. With the help of the entire group, you will gain a clear picture of the problem at hand. At the same time, you will see what is unknown and thus what requires further investigation.

Conduct the Root Cause Analysis

Use the completed cause and effect chart to assist you in searching for solutions. If you can eliminate a cause you break the link between causes and the effect wont happen. By eliminating just one cause you can demonstrate to everyone the effect that it will have by referring to your cause and effect chart. If you do end up with a large number of possible solutions, consider how to achieve the desired outcome with the least amount of time, effort, or money. Prioritise your options and implement the best of them. Establish a set of criteria by which you can objectively judge which are the better solutions.

Top tips
Follow the RCA process You dont have to be the subject matter expert, so dont profess to be one Teamwork is key value all participants contributions Keep asking why or caused by questions for as long as you need to Dont stop too soon with your questioning

Implement the solutions (corrective actions)

Implement the solutions (corrective actions)

Be clear about who is responsible for each corrective action. You dont want to create the opportunity for people to be able to pass the buck with I thought Bob was going to do it.

Your RCA should produce a number of corrective actions. These should be implemented as soon as practically possible. Have a mechanism in place by which the implementation of corrective actions can be tracked. This system should appoint a single person to each corrective action, and include a clear timeframe for completion. This allows for progress to be evaluated.

Implement the solutions (corrective actions)

Make sure you follow up on each corrective action check back with the individual responsible, to make sure that progress is being made.

Top tips
Give ownership of a solution to an individual, not a group or department Assign a due-date for each corrective action Support people in their efforts to implement corrective actions

Measure the success of the corrective actions

Measure the success of the corrective actions

By quantifying the success of your efforts, you are unequivocally demonstrating the value of RCA.

How much downtime have you avoided? How much money have you saved? Measure the impact of your RCA and its subsequent corrective actions. By talking in figures about increases in production tonnes, or a decrease in downtime, or dollars saved you will be able to demonstrate the success of your actions. After all, these measures are often the very reason you did the RCA in the first place; plus, they are tangible and readily understood by management.

Measure the success of the corrective actions

Many industries fall over when it comes to the measurement of any change that the corrective actions have engendered. Yet this step is very important. By substantiating the success of corrective actions, greater credibility is given to the investigation process and any future investigations will receive even more support from management teams.

Top tips
Identify which key performance indicators are being used to measure success Use before and after figures to prove it

Advertise your successes

Advertise your successes

By demonstrating how much value youve brought to your company, it will be easier to bring the right people to the investigative team next time around.
Publish your RCA report, and promote the great results that you measured in the previous step. As you will have discovered, the 6 steps beyond the 5 Whys require a significant investment of both time and resources. To help ensure that these resources are made available for the next RCA, then the positive outcomes of the investigation conducted should be advertised to the broader work community.

Advertise your successes

Promoting your results will engender management support for the RCA process and the process itself will gain favour and support from your colleagues. Sharing the report will also help the entire business unit to learn from the incidents or accidents that have occurred. By sharing all of your findings, you will be building on the collective wisdom of your company.

Top tips
Put the results on a poster in a prominent position Share the full report with all relevant stakeholders Share with the broader work community Quantify your successes in a way that is easy for others to understand

Case Study
Now that you have a good understanding of each of the 6 Steps Beyond the 5 Whys, lets refer back to the initial case study used to illustrate the 5 Why method and how diving deeper beyond this method, using the 6 steps, can allow you to get to the root causes of a problem. If we were to initiate the 6 Steps, a search for all relevant information would be undertaken. Statements, photographs and a search for all maintenance history on the drive motor are all collected. (Step 1) With managements support, key personnel have been identified to participate in the investigation and invited to attend. An experienced facilitator has been appointed based on their ability to handle all the individuals in the group and to control the (potentially large) group size. The room that has been booked is suited for the size of the group and the facilities allow for the recording and organisation of large amounts of information. The more room there is the better as it allows the facilitator to spread the information out in logical paths to make it easy for others to follow. The facilitator can then separate cause paths and cater for the expansion of them. (Step 2) The RCA is then undertaken (Step 3). Clarification of the purpose of the investigation, in this case preventing the recurrence of the Delay in loading the train, is the first step. Then context to the problem is included by identifying When it occurred, Where it happened and how Significant the problem is (for example; damage to reputation, cost of any demurrage for delayed shipments etc). Quantifying the costs will create an understanding of just how significant this problem is.

Next, the cause and effect chart is created. The problem is already known, so the team now undertakes an exhaustive search for all causes. Being minimalistic may speed things up but will also limit the number of opportunities that present themselves to control the problem. If minimalistic, you will probably end up with strong lineal connection of information. If expansive, we will see a chart that will grow from your initial effect and expand into a number of causal pathways. Please refer to the example below.
Action Conveyor has stopped Caused by

Condition Conveyor loads the train Primary Effect Delay in train loading Caused by Condition Only 1 Loading Conveyor Condition 6 hours to replace drive motor

Caused by

STOP

Caused by

STOP

Caused by

When expanded on further, this is what a chart starts to look like.

Condition motor operating Caused by

Action Conveyor has stopped

Caused by

Condition Drive Motor Drives conveyor Action Drive motor tripped out

Caused by

STOP

Action Bearing seized Caused by

Caused by

Caused by

Action Motor was overloaded

Condition Seized bearing overloads motor

STOP

Caused by

Condition Motor has overload protection Condition Conveyor loads the train Primary Effect Delay in train loading Caused by Condition Only 1 Loading Conveyor Condition 6 hours to replace drive motor Caused by
STOP

Caused by

Caused by

STOP

Caused by

This is before the team has even got to why the bearing has seized. Problems are rarely as simple as they seem. We tend to want to do things simply however this comes at the cost of good understanding. Whilst you may understand, it is possible that others will struggle to follow your logic. If all the information is not put into play then you rely on assumptions and a common interpretation, which is precisely why many misunderstandings occur.

Lets explore further on why the bearing seized by adding to the existing chart.

Primary Effect Bearing seized Caused by Action Metal welded together Caused by Action Temperature exceeded melting point Caused by Condition Metal melting point X Condition welding seizes the bearing Caused by

STOP

Caused by

STOP

STOP

Caused by

Action Bearing was operating

Condition High friction in bearing Caused by

Condition Didnt trip out

Caused by

Action Metal expansion in bearing Caused by Action High heat generated Caused by Caused by Action Bearing operating

Condition Minimal clearnace in bearing

Caused by

STOP

Condition Metal expands with heat

Caused by

STOP

STOP

Condition Low lubrication Caused by

Caused by

Action Tube Blocked

Condition Autolube System

Caused by

STOP

So what do we notice? The same problem has been explored, however the complexity and detail of the problem has certainly increased. If you want to establish a comprehensive understanding of the problem throughout the company, the 6 Steps Beyond 5 Whys will allow you to do this. A strong understanding of the problem will lead to implementing effective and timely solutions. (Step 4) Measuring the success of the corrective action will need to be undertaken after a period of time to ascertain the success of the solutions. (Step 5) Advertising success and sharing reports will create a positive dynamic within the company for the support of the Root Cause Analysis program, whilst also educating all employees within the company at the same time. (Step 6)

Conclusion
In this eBook, we looked at the 5 Whys process and identified that, in some cases, it does not get to the root causes of an incident or accident. Realising that you have to dive deeper, it is important to give this investigation some structure. This will help to guarantee the consistency and performance of outcomes. As the 6 steps beyond the 5 Whys demonstrates, planning and preparation are the keys to implementing a successful RCA and then initiating corrective actions. To avoid the blame game and really get to the bottom of incidents within your organisation, we encourage you to consider all the steps that have been outlined here when you next conduct an RCA that goes further than the 5 Whys process.

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onsite training
All our training courses are available for delivery onsite at your facility or a training venue of your choice. If you choose to book onsite training, we highly recommend doing the 3 day Facilitator course which offers students the opportunity to work on a real life problem from their workplace under the guidance of one of our experienced trainers.

OnSite Training Benefits

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About ARMS Reliability

ARMS Reliability is a service, software, and training organisation providing a one stop shop for Root Cause Analysis, as well as Reliability Engineering, RAMS, and Maintenance Optimisation for both new and existing projects. Since 1997, ARMS Reliability has been an authorised training provider of the Apollo Root Cause AnalysisTM methodology. In 2012, our agreement went global and ARMS Reliability now provides RCA training, software, and services throughout the world.

5 Whys + Apollo Root Cause AnalysisTM Method

Many of our clients use the 5 Whys process as their base level methodology for very simple incidents and use the Apollo Root Cause AnalysisTM method for more complex problems. The Apollo Root Cause AnalysisTM method truly is scalable it can be used for any size and complexity of problem and can be integrated into a root cause analysis program that is tailored to your organisations needs. For more information on how ARMS Reliability can help, please contact us at the office location nearest you (details below). You can also make an enquiry on www.apollorootcause.com

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