5 Why Analysis

 January 2, 2006

Global Supply Management

 5-Why Training Agenda

 Where does 5-Why Fit within the PRR process

 Understanding of 5-Why
 Quick 5-Why Exercise as a group
 Critique Sheet
 5- Why Examples
 Wrap Up/Discussion

Security Classification 2 Global Supply Management – January 2, 2006

 5-WHY

Where does it fit within the PRR process?

 After a supplier has submitted an initial response and
containment plan (Step # 2 in the PRR process), a detailed
investigation is necessary to determine what caused the
problem. Step # 4 (Supplier determines the root cause)
requires a 5-Why analysis to help in identifying the root cause
of the problem.

 Going back to one of the elements within the Purpose of a

PRR “to facilitate problem resolution”, 5-Why is the prescribed
tool for determining the root cause of the problem to facilitate
problem resolution.

Security Classification 3 Global Supply Management – January 2, 2006

 Is the powerful question… own it!!
Security Classification 4 Global Supply Management – January 2, 2006
 Power of Asking Questions

How
Speed How Fast
Limit Fast Should
Strictly Are You You Be
Enforced Going? Going?

No Cause Cause
Reaction Reaction Reaction & Research
(Look at speedometer) (Look at speedometer;
Search for speed limit sign)
Security Classification 5 Global Supply Management – January 2, 2006
 Power of Asking Questions

Who are the best at asking questions to

solve problems?

Security Classification 6 Global Supply Management – January 2, 2006

 Power of Asking Questions

Children!
Why?
…because they keep asking objective, open-ended questions
until the answer is simple and clear

When working with people to solve a problem,

it is not enough to tell them what the solution is. They
need to find out and understand the solution for
themselves. You help them do this by asking open-
ended , thought provoking questions.
Security Classification 7 Global Supply Management – January 2, 2006
 Close-Ended vs. Open-Ended Questions

Close-Ended: Structures the response to be answered

by one word, often “yes” or “no”. Usually
gives a predetermined answer.
Example: “Did the lack of standardization cause the incorrect setup? ”

Open-Ended: Leaves the form of the answer up to the

person answering which draws out more
thought or research.

Example: “How is setup controlled?”

Security Classification 8 Global Supply Management – January 2, 2006

 Benefits of Open-Ended Questions

 Requires thought
 Promotes additional research
 Enhances problem solving skills
 Does not assume there is one right answer
 Avoids predetermined answers
 Stimulates discussion
 Empowers the person answering

In many circumstances, it is not only the answer itself,

but the process by which the answer was determined
that is important when asking an Open-Ended question

Security Classification 9 Global Supply Management – January 2, 2006

 More Examples
Example 1: “Did the lack of a PM system cause this tool to break?”
(Close-Ended question, can be answered by a “yes” or “no”, gives the
person a predetermined answer that PM is to blame)

“What could have caused the tool to break?”

(Open-Ended, probing question forces the person to think about all
possibilities, not just PM)

Example 2: “Would improving material flow help reduce lead times?”

(Good question but it’s still Close-Ended, focuses the person on material
flow as a means to reduce lead time. Is this the best improvement?)

“What are some options on improving lead time?

(Open-Ended, triggering more thought and research on all variables
impacting lead time.)

Example 3: “Is equipment capability causing the variation in your process?

(Close-Ended, can be answered by a “yes” or “no”, focuses the person on
equipment being the source of variation)

“What could potentially cause variation in your process?

(Open-Ended, triggering more thought and research, opens up possibilities
of variation with man, material & method, not just machine)
Security Classification 10 Global Supply Management – January 2, 2006
 5 Why
Overview

Security Classification 11 Global Supply Management – January 2, 2006

 5-Why Analysis Three Paths

5-Why:
 Specific problem:
– Why did we have the problem?
 Problem not detected:
– Why did the problem reach the Customer?
 System failure:
– Why did our system allow it to occur?

Security Classification 12 Global Supply Management – January 2, 2006

 5-Why Analysis
Corrective Action
with Responsibility Date
Define Problem
Use this path for
the specific A
nonconformance Root Causes
being investigated

WHY? Therefore

WHY? Therefore

if i c
c
Use this path to

e
investigate why the

Sp
problem was not
detected. WHY? Therefore B

WHY? Therefore WHY? Therefore

n
A

WHY?

ct io
Therefore

Use this path to

ete
investigate the
systemic root cause
(Quality System
Failures)
D
WHY? Therefore

c
WHY? Therefore WHY? Therefore

i
t em
B

s
Ref. No. (Spill, PR/R…) WHY? Therefore

Date of Spill Sy WHY? Therefore

Product / Process Delphi Location Content Latest Rev Date WHY? Therefore

Problem Resolution Complete Communicate to Delphi Date: Process Change Break Point Date: Implement System Change Date:

Lessons Learned:

Security Classification 13 Global Supply Management – January 2, 2006

 Root Cause Analysis

Delco fuse box

Insert example

What tool do
We use for this?

Security Classification 14 Global Supply Management – January 2, 2006

 Brainstorming

Security Classification 15 Global Supply Management – January 2, 2006

 Grasp the Situation

 Part I – Grasp the Situation

– Step 1: Identify the Problem
» In the first step of the process, you become aware of a problem that may be
large, vague, or complicated. You have some information, but do not have
detailed facts. Ask:
» What do I know?
– Step 2: Clarify the Problem
» The next step in the process is to clarify the problem. To gain a more clear
understanding, ask:
» What is actually happening?
» What should be happening?
– Step 3: Break Down the Problem
» At this point, break the problem down into smaller, individual elements, if
necessary.
» What else do I know about the problem?
» Are there other sub-problems?

Security Classification 16 Global Supply Management – January 2, 2006

 Grasp the Situation

– Step 4: Locate the Point of Cause (PoC)

» Now, the focus is on locating the actual point of cause of the problem. You
need to track back to see the point of cause first-hand. Ask:
» Where do I need to go?
» What do I need to see?
» Who might have information about the problem?
– Step 5: Grasp the Tendency of the Problem
» To grasp the tendency of the problem, ask:
» Who?
» Which?
» When?
» How often?
» How much?
» It is important to ask these questions before asking “Why?”

Security Classification 17 Global Supply Management – January 2, 2006

 5-Why Analysis

 Step 1: Problem Statement

– Is the problem statement clear & accurate?
– Is the analysis on the problem as the customer sees it?
 Step 2: Three Paths
– Are all three legs filled in?
– Are there any leaps in logic?
– Can you ask one, two, or three more Whys?
– Is there a cause-and-effect relationship in each path?
– Can the problem be turned “on” and “off”?
– Does the path make sense when read in reverse?
– Do the whys relate to the actual error?
– Does the non-conformance path tie to design, operations, dimensional issues,
etc.?
– Does the detection path tie to the customer, control plans, etc.?
– Does the systemic path tie to management issues or quality system failures?

Security Classification 18 Global Supply Management – January 2, 2006

 5-Why Analysis

 Step 3: Corrective Actions

– Is there a separate action for each root cause?
– Is it possible to implement each corrective action?
– Do corrective actions require Customer approval? If so, how will they be
communicated to the Customer?
– Is there evidence to support verification of corrective actions?
– Are corrective actions irreversible?If not, do actions address ongoing
containment?
– Is there a plan to standardize lessons learned across products, departments, etc?
 Step 4: Lessons Learned
– How could the problem have been foreseen?
– How will information be implemented?
» On the line or in the plant?
» At the point of detection?
» Cross functionally at the Supplier?
» Other products/plants?

Security Classification 19 Global Supply Management – January 2, 2006

 5-Why Analysis

 Step 5: Overall
– Are there gaps or “holes?”
» Are there things missed or not documented?
– Do corrective actions address actions the Supplier owns?
– How many iterations of 5 Why Analysis have there been?
– Who prepared the 5 Why Analysis?
» One person?
» Sales representative ?
» Clerk?
» The best answer is a cross functional team that understand the product and
process!

Security Classification 20 Global Supply Management – January 2, 2006

 Therefore Test

Security Classification 21 Global Supply Management – January 2, 2006

 5-Why Analysis
The problem is stated through
Problem the eyes of the customer

The first why is the main cause

The second why is what

Th
causes the main cause

er
ef
Etc.

o
W

re
hy
?

Etc.
You have root cause if you
Root Cause can demonstrate:
• cause on, problem on
• cause off, problem off

Security Classification 22 Global Supply Management – January 2, 2006

 5-Why Example
(Non-conformance)

Problem Cookies taste really bad

Cookies are undercooked

Th
er
ef
Ingredients are wrong

or
W

e
hy

Used goose eggs rather than

?

chicken eggs

Root Cause Recipe did not specify bird type

Security Classification 23 Global Supply Management – January 2, 2006

 5-Why Example - PPAP Submittal
(Non-conformance)

Problem PPAP submitted late

PPAP package not complete

Th
er
ef
Validation testing not complete

or
W

e
hy

Test lead time not considered

?

No system to accurately assess

Root Cause lead times of all PPAP elements

Security Classification 24 Global Supply Management – January 2, 2006

 5-Why Example - PPAP Submittal
(Detection)

Problem PPAP submitted late

Did not react to the target

submittal date

Th
er
Did not know the target

ef
submittal date had passed

or
W

e
hy

No requirement to follow-up on
?

target submittal dates

No standard system to manage

Root Cause PPAP submittal timeliness

Security Classification 25 Global Supply Management – January 2, 2006

 5-Why Example - Business Plan
(Non-conformance)

Problem Did not meet the annual business

plan goal of a 10% increase in sales

Did not thoroughly evaluate

Th
market/competition

er
Did not have adequate

ef
resources

or
W
hy

e
Did not anticipate required
?

resources

Did not develop a plan as to

Root Cause “how” the goal would be reached

Security Classification 26 Global Supply Management – January 2, 2006

 5-Why Example - Business Plan
(Detection)

Did not meet the annual business

Problem plan goal of a 10% increase in sales

Did not know the goal was not

going to be met

Th
er
Did not evaluate the status of

ef
the goal until December

or
W
hy

e
Did not have alarms limits
?

identified at strategic intervals

(monthly, quarterly, etc.)

Root Cause Did not develop a plan to monitor

the status of reaching the goal

Security Classification 27 Global Supply Management – January 2, 2006

 Flex Industries Case Study-
Background

 Jake Ryan is the Quality Manager at Flex Industries. Flex is a component

supplier that manufactures metal stampings and light assembly products.
The company has a reputation for supplying high quality parts on a
consistent basis. Seldom has there been a customer complaint. Flex has
Quality representatives called Customer Support Engineers (CSE’s) at every
customer assembly plant. The CSE’s report any problems to Jake for
investigation and follow-up.

 At 7:00 a.m. this morning, Jake received a call from Janet, CSE at the
Winding River Assembly Plant. Janet informed him that the customer had
found five defective stabilizing brackets on second shift last night. She
checked the remaining inventory and there were no defects in the remaining
326 pieces. The manufacturing sticker on the back of the brackets indicated
that they were made by the second shift operator. Normally, the stabilizing
bracket is fastened to the regulator motor with three rivets. The five
defective brackets had only two rivets in them. The lower set of rivets on all
five brackets was missing a rivet. This was the first time that the problem
occurred.

Security Classification 28 Global Supply Management – January 2, 2006

 Background

GOOD BAD

Jake set-up containment procedures at the plant warehouse to sort for discrepant materials. As
of this morning, two more defective brackets had been found in the remaining 2019 pieces of
inventory at Flex.

Security Classification 29 Global Supply Management – January 2, 2006

 Cause Investigation
 Jake went out to the floor to talk with the team leader of the two rivet lines
(East and West) and the area quality assurance auditor. He informed Sam
(the team leader) of the quality problem and asked him to identify the line
which runs the stabilizing bracket assembly. Sam directed Jake to the East
line which runs Winding River assembly brackets only.
 At the East Line, he spoke with Judy (the QA Auditor for the area) and asked
to see the quality log sheets. Jake and Judy reviewed the Nov. 11 th log
sheet and could not find anything out of the ordinary. He asked her to set-up
in-house containment procedures to sort for any discrepant material in the
finished goods area.
 Next, Jake tried to locate the second shift operator whose clock number was
on the defective parts. Since that operator was gone, Jake spoke with the
current machine operator (Ben). He asked Ben about any recent difficulties
with the rivet machine. Ben said that he hadn’t noticed anything out of the
ordinary. Ben also mentioned, however, that there had never been any
quality bulletins posted in the two years that this particular part has been
running.
 Jake decided to stay in the area to watch the machine run for a while. After
about 15 minutes, he watched Ben dump rivets into the feeder bowl to
prepare for the next run.
Security Classification 30 Global Supply Management – January 2, 2006
 Cause Investigation

 Shortly after restarting rivet operations, Ben walked over to another riveter
and came back with a steel rod. Ben poked around the rivet chute and then
continued working. Jake approached Ben and asked him about the steel
rod. Ben replied that from time to time the chute gets jammed and he has to
clear it out. This happens two or three times during a shift. He didn’t
mention this in his earlier conversation with Jake because the problem has
existed ever since he started working with this machine. The previous
operator showed him how to clear the chute. All the rivet machines are like
this.
 Jake called the Machine Repair Department and asked that someone look at
the rivet track. A slight gap in the track was found and removed, and Ben
continued to work.
 Two hours later, Jake got a call from Ben saying that the track was still
jamming. As far as Jake could see, only rivets were in the bowl. Next, Jake
looked into the rivet supplier containers. There was some foreign material in
the blue container, but none in the red container. The label on the blue
container showed that it was from Ajax Rivet, Inc., and the label on the red
container indicated that it was from Frank’s Fasteners. Obviously, the
foreign material was entering the rivet feeder bowl and jamming the track.

Security Classification 31 Global Supply Management – January 2, 2006

 Cause Investigation

 Jake called Maintenance and requested that the bowl be cleaned. He also
added the cleaning operation to the preventive maintenance schedule on the
equipment. He then called both Ajax Rivet, Inc. and Frank’s Fasteners. He
asked about the cleaning procedures on the returnable containers. Frank’s
did a full container purge and clean. Ajax just re-introduced the containers
back into their system. When Jake asked why Ajax did not clean their
containers, he was told that Ajax was not aware that such a policy was
needed.
 Upon further investigation, Jake learned that Frank’s Fasteners supplies
other major automotive companies. Since these companies require that all
returnable containers be cleaned, Frank’s instituted the purge as part of its
practice for all customers. Ajax Rivet, however, depends primarily on Flex as
its major customer. No such policy has ever been required of them.

Security Classification 32 Global Supply Management – January 2, 2006

 Cause Investigation

 Jake called the Material Control Department and requested that

a container maintenance policy be drafted which would apply to
all their suppliers. He also asked that a machine modification
be developed to sense for the presence of rivets. Hopefully, this
would error-roof the process.
 Key Players
– Jake Quality Manager
– Janet CSE, Winding River Plant
– Sam Team Leader, East Line
– Judy QA Auditor, East Line
– Ben Machine Operator

Security Classification 33 Global Supply Management – January 2, 2006

 Generic Information for 5-Why Example:
Regular Cola Soft Drink vs. Diet Cola

 The plant received a PR/R from a customer. (We use 5-Why

Analysis to answer every PR/R.)
 The PR/R states that the customer received “Regular Cola in the
right container (same for both products) with the Diet Cola label”.
The order called for Regular Cola.
 The plant has two identical lines that are capable of running either
of our two products. The lines are located immediately beside
each other. The only differences in the products are the syrup and
the labels.
 The plant runs both lines 24 hours per day. There are three shifts
that run 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00
p.m. to 7:00 a.m.
 The date code indicates that the defective product was
manufactured at 3:03 p.m.
 Defective product has been contained and sorted.
Security Classification 34 Global Supply Management – January 2, 2006
 Bottling Process Flow for 5-Why

BOTTLES B LIDS
O
T
T
WATER INSPECT
L
I
N
SYRUP G LABELS

Security Classification 35 Global Supply Management – January 2, 2006

 Generic Information for 5-Why Real
Example: “O” Ring Seal

 The plant received a PR/R from a customer. (We use 5-Why

Analysis to answer every PR/R.)
 The PR/R states that the customer received “Mixed/Foreign
Material in Shipment”.
 The supplied part is an “O” Ring seal for oil filter.
 A cutting operation produces the part to specified size. As the raw
material (cylindrical component) goes through the cutting
operation, the irregular end-cuts are removed from the station.

Cutting Station

Mat’l Flow

Security Classification 36 Global Supply Management – January 2, 2006

 Is this a good or bad
“Non-Conformance” leg?

Missing o-ring
on part number
K10001J

WHY?
Parts missed the
o-ring installation
process

WHY?
Parts had to be Why did they
reworked have to rework?

WHY?

Operator did not return

parts to the proper process
step after rework

WHY?
No standard rework
procedures exist

This is still a systemic failure

& needs to be addressed,
but it’s not the root cause.
Security Classification 37 Global Supply Management – January 2, 2006
 Is this a good or bad “Detection” leg?

Missing threads
on fastener part
number LB123

WHY?
Did not detect
threads were What caused
missing the sensor to
get damaged?
WHY?
Sensor to detect
thread presence
was not working

WHY?

Sensor was
damaged

WHY?
No system to
assure sensors are
working properly
This is still a systemic failure
& needs to be addressed,
but it’s not the root cause
Security Classification of the lack38of detection. Global Supply Management – January 2, 2006
 A good 5-Why will answer “Yes” to the five
PDCA questions:

“A problem well defined

is a problem half solved”

ACT
Standardize
PLAN
Understand the problem

5. Has a plan been identified 1. Is the problem statement

to STANDARDIZE and take CLEAR and ACCURATE?
all lessons learned across
products, processes, 2. Has the SYSTEMIC
plants, functional areas, etc.? root cause(s) been
identified for all legs?

CHECK
Follow-up
DO
Execute the Plan

4. Has a plan been identified 3. Has IRREVERSIBLE

to verify the CORRECTIVE ACTION(s)
EFFECTIVENESS been implemented for
of all corrective ALL root causes?
actions?

Security Classification 39 Global Supply Management – January 2, 2006

 Is this a good Corrective Action plan?
Corrective Action
w/ Responsibility Date
Plan
Fastener P/N 10001
A
would not assemble
Do 1. Replace worn tool 6/1/03
WHY? (K. Jones)
Burrs on the thread
Do/Act 2. Begin conducting PM on all 6/1/03
dies after every run, minimum
WHY?
1 x / day, to collect history
(L. Burg)
Worn stamping
tool
Do/Act 3. Assess & adjust PM intervals 7/31/03
for all dies based on history
WHY?
& mfg recommendations
Tool exceeded (B. Clark)
recommended wear
life
Check
WHY? 4. Track PM completion % 6/1/03
PM interval not to assure 100% conformance
adequate (C. Beckett)
Plan Check
WHY?
5. Check for burrs on threads 6/1/03 -
for 60 days to verify c/a 7/31/03
PM failure; No system
(M. Mendoeous)
to strategically set A
PM intervals Check
6. Track FTQ at stamping to 6/1/03
monitor PM improvement
(S. Boland)
Security Classification 40 Global Supply Management – January 2, 2006
 5-Why Critique Sheet

 General Guidelines: A.) Don’t jump to conclusions!; B.) Be absolutely objective. C.) Don’t assume the answer is
obvious. D.) If you are not thoroughly familiar with the process yourself, assemble a cross-functional team to
complete the analysis.

 Step 1: Problem Statement

Is the analysis being reported on the problem as the Customer sees it?

 Step 2: Three Paths (Dimensional, Detection, Systemic)

-Are there any leaps in logic?
-Is this as far as the Whys lead? Can you still ask one, two, three more why’s)?
-Is there a true cause-and-effect path from beginning to end of each path? Is there statistical data/evidence to
prove it? ---Can the problem be turned off and on?
-Does the path make sense when read in reverse from cause to cause? (e.g.—We did this, so this happened, so
this happened, and so on, which resulted in the original problem.)
-Do the why’s go back to the actual error?
-Does the systemic path tie back to management systems/issues?
-Does the nonconformance path ties back to issues such as design, operational, tiered supplier management,
etc…?
-Does the detection path ties back to issues such as protect the customer, control plans, etc…?

Security Classification 41 Global Supply Management – January 2, 2006

 5-Why Critique Sheet (cont)
 Step 3: Corrective Actions
-Does each corrective action address the root cause from a path?
-Is there a separate corrective action for each root cause? If not, does it make sense that the corrective action
applies to more than one root cause?
-Is each corrective action possible to implement?
-Are there corrective actions that affect the Customer or require customer approval? How will they be
communicated to the Customer?
-Is there evidence and documentation to support the validity of the corrective actions?
-Are the corrective actions irreversible? If not, are there corrective actions in place that address containment?
 Step 4: Lessons Learned
-How could this problem have been foreseen?
-How will this information be implemented:
a.) on the line or in the plant?
b.) at the point of detection?
c.) cross-functionally at the Supplier?
d.) other product/plants?
-Are there lessons learned for the Customer?
 Step 5: Overall
-Do there seem to be big holes where ideas, causes,
corrective actions, or lessons learned are being avoided?
-Where things are missed or not documented?
-Do the corrective actions address the actions the supplier owns?
-How many iterations has the supplier gone through so far in preparing
this 5-why (It doesn’t happen on the first try!)
-Who prepared the 5-why?
Security Classification 42 Global Supply Management – January 2, 2006
 5-Why Analysis: Cola Example –
Path A

Security Classification 43 Global Supply Management – January 2, 2006

 5-Why Analysis: Cola Example –
Path B

Security Classification 44 Global Supply Management – January 2, 2006

 5-Why Analysis: Cola Example –
Path C

Security Classification 45 Global Supply Management – January 2, 2006

 5-Why Analysis: “O”Ring
Example – Path A

Security Classification 46 Global Supply Management – January 2, 2006

 5-Why Analysis: “O”Ring
Example – Path B

Security Classification 47 Global Supply Management – January 2, 2006

 5-Why Analysis: “O”Ring
Example – Path C

Security Classification 48 Global Supply Management – January 2, 2006

 Problem Case Audit Standards

 5-Why Analysis: Green, Yellow, Red

– G: Can follow logic and flow of all 3 legs of 5 why's. The legs all
differentiate "What is the problem, why wasn't it detected, and what
happened systemically."
– Y: All 3 legs filled out, some leaps of logic, needs minor corrections to
improve.
– R: 1 or 2 legs missing, Leg 1 repeated as leg 2 or 3, not understanding
what the different legs mean--typically missing what the systemic leg is.
Poor answers on 2 or more legs.

Security Classification 49 Global Supply Management – January 2, 2006