Rockwell 3x5 Why Analysis Audio

8/17/2019 Rockwell 3x5 Why Analysis Audio

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© 2014 Rockwell Collins.All rights reserved.


3375 Armar DriveMarion, Iowa 52302

319-398-7101www.iowaqc.org

3 Legged “5 Why”

Root Cause Analysis

Making Customers Central To All That We Do

April 24, 2014John Heise, CLSSMBB, CQM, Iowa Quality Center


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3 Legged “5 Why” Root Cause Analysis Training

Course Objectives

• Understand the purpose of 3 legged “5 Why” (“3x5Why”) Root Cause Analysis

• Learn the basic components of a “3x5 Why”

• Develop the skills needed to perform a “3x5 Why”Analysis with confidence

I hear, I forget.

I see, I remember.

I do, I understand.

- Chinese Proverb

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3x5 Why Root Cause Analysis

What is it?

The “5 Why’s?” is the most basic form of Root Cause Analysis

Simple: Ask “why?” until you can’t ask “why?” anymore

Focused on a particular problem or effect: typically undesirable

“3x5 Why’s?”: an approach to determine all possible causesthat lead to the effect (issue)

Broken down into three key areas:

1. Direct Cause: The Immediate reason for the effect

2. Detectability: Reason nonconformity was not caught

3. Systemic Cause: Reason system allowed problem to occur

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3x5 Why Root Cause Analysis Example

When completed, can be very simple or quite involved.

It all depends on the complexity of the issue.

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Defining Root Causes

When investigating effects and causes: Start with a description of the process issue.

May be multiple things working together, or

A “chain” of events

We refer to the key input issue, or issue starting the “chain of

events”, as the “Root Cause”

Key to success: good description of the “effect”

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Effect

Cause 1 Cause 2 Cause 3

Effect

Cause 1

Cause 2

Cause 3

Key ause or

“Root ause”

Key ause or

“Root ause”


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When to use a “3x5 Why?”:

When people do not understand the issue

Need a better understanding of what is driving the issue

Need to identify possible causes

Need to investigate an issue quickly

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When to use “3x5 Why?”:

When you can answer "Yes" to these questions:

1. Do root causes of a problem need to be identified?

Allows the quick identification of "why" an issue exists

2. Are there many ideas and/or opinions about the causes of a

problem? People have formed opinions of the potential cause(s)

Opinions may conflict or fail to identify the root cause

3. Need to know how the issue was allowed to happen?

How was the issue not caught by current quality systems?

What key work processes, procedures, etc. allowed the issue to bepresent?

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Using a "3x5 Why" Analysis makes it possible to quicklycapture the key (root) causes of an issue for possible study



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Why use “3x5 Why?”:

Help prevent team from jumping to solution

To encourage people to use higher order thinking skills

To cut through the layers of bureaucracy to find the truereasons why an issue exists

To challenge current thinking and/or paradigms

To help people understand the root cause(s) of a problem

To help people clarify motivation for change

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Where can “3 by 5 Why?” Analysis be used: In situations requiring better understanding and/or knowledge

In manufacturing, investigating part defects or productiondowntime

In office work processes, understanding causes of issues orerrors

In markets or service operations, looking for causes ofcustomer complaints

With product issues or returns, looking for causes of failures orreduced performance

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Are there areas of issues you can think ofthat you can apply the “3 by 5 Whys”?


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3x5 Why Root Cause Analysis Process

How is it made

1. Identify the problem to be studied

2. Assess the immediate reasons (Direct Cause) why the issueoccurred

3. As applicable for the issue, assess "Why?" the issue was notdetected (Detectability)

4. Using the "Direct Cause" & "Detectability" root causes, identifythe systemic cause(s) that allowed the issue to occur

5. Develop a "Theory of Improvement" (proposed solution) fromthe "5-Why's?" analysis

6. Assess the "Theory of Improvement" to ensure it will provide asound (permanent) solution

Let’s look at each step…

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1. Identify the Problem What problem (effect) needs to be improved and/or

controlled?

Typically described by a failure mode or undesirable event

Description of the problem should be short and specific

Does not contain a proposed solution!

Example: Scratches or missing paint is being seen onbezel push-buttons received from supplier

Enter a clear description of the observed nonconformity in

the Problem Statement field.

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Note: The causes will vary depending on the effect!

3x5 Why Process


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3x5 Why Process

2. Assess the immediate reasons why the issue occurredusing the Direct Cause leg.

Ask "Why?" does this condition or problem exist?

Example: Why do we have scratches and missing paint on bezel push-buttons?

Each time the question "Why?" is answered, ask "Why?" again

Continue to ask "Why?" until all are satisfied they are at the rootcause

Can give insight into what containment activities can be done

Often, we look for blame rather than causation – focus should be onthe system, not the individual

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Asking "Why?" should not be a futile effort; refrain from doing thisfrivolously. Make sure everyone is making a serious effort to answer

the question "Why?".


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3x5 Why Process

Step 2 Example:

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There can be multiple reasons (causes) why the issue exists.Start another leg if needed.


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3. Next, as applicable for the defect/issue

occurrence, assess "Why?" the issue was notdetected using the Detectability leg.

Focus on the inspection and/or testing methods used in thework process.

Again, start by asking "Why?" did we not detect this issue or

error when it occurred?

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3x5 Why Process


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3x5 Why Process

4. Using the root causes in the "Direct Cause" and"Detectability" legs, dive deeper into identifying theassociated systemic cause(s) that allowed the issue or

error to occur.

Record results in the "Systemic Cause" leg

Ask "Why?" current systems didn't do the right job the firsttime through to provide the customer what they wanted orexpected

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3x5 Why Process

5. Develop a "Theory of Improvement" (proposedsolution) from the chain of answers given to the "5-Why's?" analysis.

For each leg, identify corrective action needed to resolve

root cause(s) Record information in Corrective Action fields on the "3x5

Why's?" Template

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3x5 Why Process

6. Assess the "Theory of Improvement" to ensure it

will provide the sound (permanent) solution theteam, or organization, is looking for.

Great tools to use: the "If-Then" or Force Field Analysis.

When satisfied: attach completed 3x5 Why Template to 8D

Task (GC02 from the GENCA task group) in the ActionRequest (AR)

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3x5 Why Example

A completed “3x5 Why?” Analysis may look like this:

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Multi-Leg 5 Why Example

This example shows just how spread out a “5-Why” can get:

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3x5 Why Best Practices

Things to Consider:

• Identify and verify the most likely causes

• If multiple root causes - consider using an InterrelationshipDiagram to identify true (driving) key root causes

• Root causes can and should be verified

– Collecting data and/or information on the work process, or

– Perform planned experiments

• Causes are verified in two ways:

1. The effect is present when the cause is present, or

2. When the cause isn't present, the effect doesn't exist

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Things to Consider (con’t):• Note: multiple causes can produce the same effect, or

• A root cause can produce multiple effects

• If multiple causes:

– Consider which causes are occurring the most (frequency and/ordowntime), or having the biggest impact ($ loss),

– Assess them using a Pareto diagram; take action first on the Top20% that are causing 80% of the effect

• The greatest success in improvement is achieved by identifying,verifying, and removing those causes that contribute the most

to producing the effect

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Getting the most out of your “3x5 Why?” Analysis:

• Pull together a good cross-functional team (4-8 people): peoplefrom the process, a subject matter expert, a supplier, thecustomer or customer representative, and someone “fresh” tothe process

• You can always do more than five whys, but try not to do lessthan five

• DO "all three legs": Direct Cause, Detectability, Systemic Cause

– 1st-pass: defining the immediate root cause

– 2nd-pass: understanding why inspection/test methods did not work

– 3rd-pass: what Systemic weakness or breakdown allowed theproblem to occur

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Getting the most (con’t):

• Just like the C&E Diagram, "3x5 Why's?" can be carried out onmany levels

– Primary analysis is done to find the most likely cause

– Use this most likely cause for the effect (or problem statement) fornext level "3x5 Why?" Analysis

• Mental blocks can occur when searching for root causes

– When this happens, “walk the process” to look for possible causes

• Keep in mind: the more levels - the better the results

– The true root causes may be hidden several levels below the more

easily identified causes

• Follow each use of the tool with a debriefing session

– Allow individuals the chance to share their learning’s with others

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3x5 Why Root Cause Analysis Summary

A “3x5 Why’s?” Analysis is:

The most basic form of Root Cause Analysis

Focused on a particular undesirable problem or effect

An approach to determine all possible causes that lead to theeffect (issue)

“3x5 Why’s?” Analysis helps to:

1. Find the immediate reason (Direct Cause) for the effect

2. Find the reason the nonconformity was not caught(Detectability)

3. Find the reason system allowed problem to occur (SystemicCause)

4. Determine the best course of action to resolve the issue

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© 2014 Rockwell Collins.All rights reserved

Thank You

To learn more about Root Cause Analysis or other Quality Tools,contact:

Iowa Quality Center

3375 Armar Drive

Marion, Iowa 52302

(319) 398-7101

www.iowaqc.org

On Facebook at: Iowa Quality Center

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Rockwell 3x5 Why Analysis Audio