©2015 Ford Motor Company

“A Focused Approach to Solving Chronic

and/or Systemic Problems"

©2015 Ford Motor Company 1

 Looking Deep to Find
Systemic Weaknesses

©2015 Ford Motor Company 2

 3 Legged 5 Why Analysis
– A Very Basic Approach
• Identify Specific Root Cause(s) (How was the defect produced?)
• Identify Detection Root Cause(s) (How did the controls fail ?)
• Identify Systemic Root Cause(s) (Management System Weakness?)
– Extremely easy to Explain
– Extremely difficult to do Correctly

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A Creative Problem Solving Model…

Problem
Identified Problem
Clarified Select
Solution

Fact
Finding Generate
Ideas Implement
Solution

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 Customers know when they are
unhappy.
Customers describe problems in
“their” terms.
Customers describe what they can
see.
What customers can see are
usually symptoms of the problem.

©2015 Ford Motor Company 5

 There are usually many issues to consider.
People often respond too quickly and take a symptom or
middle step as root cause.
Problem solvers need to be quick, effective and strategic.
A good problem description is an important starting point to
determine root cause

©2015 Ford Motor Company 6

3 Legged 5 Why: A Focused
Approach to Problem Solving

How was it created?

How did we miss it?

How did our system fail?

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 Direct root cause: How did the problem occur?
– Start with the actual problem.
– Keep the focus simple.

Detection root cause: How did the problem escape?

– Focus on inspection system.
– How did it fail?
– Did we account for problem in our Detection Processes?

Systemic root cause: Why didn’t our systems protect the

customer?
– Start with the Specific Root Cause
– Look at the problem from a bigger perspective.
– Find organizational flaws.

©2015 Ford Motor Company 8

 Clearly define and describe
the problem.
Ask, “Why?” as many times
as necessary (usually FIVE
times).
Check your analysis with the
“therefore” test.

©2015 Ford Motor Company 9

 The following poem reveals the heart of the 5 Why
Process:
– For want of a nail, the shoe was lost.
– For want of a shoe, the horse was lost.
– For want of a horse, the warrior was lost.
– For want of a warrior, the battle was lost.
– For want of a battle, the kingdom was lost.
– All for want of a nail.

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The Kingdom and the Nail

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Use the “therefore” test for logic
Castle burned

For want of a nail, the shoe was lost. Therefore

For want of a shoe, the horse was lost. Battlefield had no

For want of a horse, the warrior was lost. soldier

For want of a warrior, the battle was lost. Therefore

For want of a battle, the kingdom was lost. Soldier had no horse
All for want of a nail.
Therefore
Horse had no shoes

Blacksmith had no Therefore

nails

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5 Why on the Kingdom
1st level: “We lost the battle last week.
Why did we lose the battle?”

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5 Why on the Kingdom
1st level: “We lost the battle last week.
Why did we lose the battle?”
2nd level: “It was close! They had one
more warrior than us, and that made the
difference. I heard Smith was available.
Why wasn’t he there?”

©2015 Ford Motor Company 14

5 Why on the Kingdom
1st level: “We lost the battle last week.
Why did we lose the battle?”
2nd level: “It was close! They had one
more warrior than us, and that made the
difference. I heard Smith was available.
Why wasn’t he there?”
3rd level: “He didn’t have a horse to ride.”
“But, there was a horse available. Why
wasn’t it used?”

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5 Why on the Kingdom
1st level: “We lost the battle last
week. Why did we lose the battle?”
2nd level: “It was close! They had one
more warrior than us, and that made
the difference.” “I heard Smith was
available. Why wasn’t he there?”
3rd level: “He didn’t have a horse to
ride.” “But, there was a horse
available. Why wasn’t it used?”
4th level: “It was missing a shoe and
would not have lasted through the
battle.” “Why didn’t the horse have a
shoe?”

©2015 Ford Motor Company 16

5 Why on the Kingdom
1st level: “We lost the battle last week.
Why did we lose the battle?”
2nd level: “It was close! They had one
more warrior than us, and that made the
difference.” “I heard Smith was available.
Why wasn’t he there?"
3rd level: “He didn’t have a horse to
ride.” “But, there was a horse
available. Why wasn’t it used?”
4th level: “It was missing a shoe and
would not have lasted through the
battle.” “Why didn’t the horse have a
shoe?”
5th level: “The shoe fell off because it
didn’t have enough nails. The blacksmith
ran out of nails.”

©2015 Ford Motor Company 17

5 Why on the Kingdom The Test: Reverse Logic
1st level: “We lost the battle last
week. Why did we lose the battle?”
2nd level: “It was close! They had one
more warrior than us, and that made the
difference.” “I heard Smith was
available. Why wasn’t he there?”
3rd level: “He didn’t have a horse to
ride.” “But, there was a horse available.
Why wasn’t it used?”
4th level: “It was missing a shoe and
would not have lasted through the
battle.” “Why didn’t the horse have a
shoe?”
THEREFORE
The shoe fell off.
5th level: “The shoe fell off, because
it didn’t have enough nails. The
blacksmith ran out of nails.”

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5 Why on the Kingdom The Test: Reverse Logic
1st level: “We lost the battle last
week. Why did we lose the battle?”
2nd level: “It was close! They had one
more warrior than us, and that made the
difference.” “I heard Smith was
available. Why wasn’t he there?”
3rd level: “He didn’t have a horse to
ride.” “But, there was a horse available. THEREFORE
Why wasn’t it used?” The horse was unavailable for
4th level: “It was missing a shoe and battle.
would not have lasted through the
battle.” “Why didn’t the horse have a
shoe?”
5th level: “The shoe fell off, because it
THEREFORE
didn’t have enough nails. The The shoe fell off.
blacksmith ran out of nails.”

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5 Why on the Kingdom The Test: Reverse Logic
1st level: We lost the battle last week.
Why did we lose the battle?
2nd level: It was close. They had one
more warrior than us, and that made
the difference. I heard Smith was
available. Why wasn’t He there? THEREFORE
3rd level: He didn’t have a horse to A soldier was removed from
ride. There was a horse available. Why the battle.
wasn’t it used?
4th level: It was missing a shoe and THEREFORE
would not have lasted through the The horse was unavailable for
battle. Why didn’t the horse have a battle.
shoe?
5th level: “The shoe fell off, because it THEREFORE
didn’t have enough nails. The The shoe fell off.
blacksmith ran out of nails.”

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5 Why on the Kingdom The Test: Reverse Logic
1st level: We lost the battle last week.
Why did we lose the battle? THEREFORE
2nd level: It was close. They had one The battle was lost.
more warrior than us, and that made the
difference. I heard Smith was available.
Why wasn’t He there?
THEREFORE
A soldier was removed from
3rd level: He didn’t have a horse to ride. the battle.
There was a horse available. Why wasn’t
it used?
THEREFORE
4th level: It was missing a shoe and would The horse was unavailable for
not have lasted through the battle. Why
didn’t the horse have a shoe? battle.
5th level: “The shoe fell off, because it THEREFORE
didn’t have enough nails. The blacksmith The shoe fell off.
ran out of nails.

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 5 Why on the Kingdom The Test: Reverse Logic
1st level: We lost the battle last THEREFORE
week. Why did we lose the battle? The enemy took over the
2nd level: It was close. They had one kingdom.
more warrior than us, and that made
the difference. I heard Smith was THEREFORE
available. Why wasn’t He there? The battle was lost.
3rd level: He didn’t have a horse to THEREFORE
ride. There was a horse available. Why A soldier was removed from
wasn’t it used? the battle.
4th level: It was missing a shoe and
would not have lasted through the THEREFORE
battle. Why didn’t the horse have a The horse was unavailable for
shoe? battle.
5th level: “The shoe fell off, because it
didn’t have enough nails. The
THEREFORE
blacksmith ran out of nails.” The shoe fell off.

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Specific: Why did this specific situation happen? (What caused
the failure to occur?)
Detection: Why was the situation overlooked? (Why didn’t we
detect the failure before it reached the customer?)
Systemic: Why did the possibility exist for this situation to
occur? (What is lacking in our Quality Operating System?)

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 Why

Why

Why

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 Result
Not Enough
Nails

Why Nail Inventory Not

Correct

Why Number of nails

required not known

Number of Horses
Why and Number of Nails
not compared

No One assigned
Why to verify nails to
horse ratio

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 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.

©2015 Ford Motor Company 27

 Missing threads
on fastener part
number LB123
WHY?
Did not detect What caused
threads were
the sensor to
missing
get damaged?
WHY?
Sensor to detect
thread presence
was not working
WHY?

Sensor was
damaged
WHY?
No system to
assure sensors
are
This is still a systemic failure working properly
& needs to be addressed,
but it’s not the root cause
of the lack of detection.

©2015 Ford Motor Company 28

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 May be multiple Systemic
issues to consider
They should always point at the
management systems that are in
place (i.e., your Quality Operating
System)
Problem solving teams need to
involve the right people in
management to help with the
systemic leg of the 5 Why

©2015 Ford Motor Company 30

 32

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 Bill of Process not comprehensive
– PFMEA
– Process Flow Diagram
– Control Plan
– Changeover Process/Procedure
– Preventative/Gage Maintenance
– Error and Mistake Proofing
Process controls inadequate
– SPC Limits / Sample Size
– First Time Capability Alarm
– Operator Work Instructions
– Lot Traceability

©2015 Ford Motor Company 32

 Quality system non-conformance
– Improper changeover
– Inadequate control of non- conforming
product
– Failure to act on early warning
– Failure to follow procedures
Change management
– Change process not followed
– Customer not properly informed
– Documentation (D/PFMEA, Control
Plan, Work Instruction) not updated prior
to implementation

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 DFMEAs
PFMEAs
Control Plans
Operator Work Instructions
Maintenance Schedules
Maintenance Procedures
Corporate Documentation
Lessons learned Database/Libraries

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 The same system set up other operations.
The same weaknesses are probably there.
The key to winning is to apply lessons learned to other
operations.
You must prevent duplicate problems from occurring!

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 37

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 Sharing lessons learned allows you to turn
negatives into positives.
Duplicating lessons learned increases:
– First-time yield
– Margins
– Profits
– Customer satisfaction
Sharing lessons learned forces growth in
knowledge inventory.
Perform the operations “look/read across.”

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5 Why Analysis is an Effective Technique
Customer describes problem.
– Supplier creates precise description.
– Customer helps in analysis.
– Supplier looks at problem from three
perspectives:
• Specific (Direct) cause
• Detection (Escape) cause
• Systemic cause

Supplier puts actions in place to eliminate all causes

and make processes/procedures robust.

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 Drives corrective actions for all 3 Legs
Separates “noise” from real issues
Forces people to “dig deep”
into processes, procedures,
data
Makes management issues visible
Provides focus for the efforts of the
cross functional team

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