#PACE : Tip of the Day_010

5 WHY,…A Proven Technique for Root Cause Analysis

We encounter daily situations where an unwanted failure, incident or accident requires a Root Cause Analysis (RCA) to be done so that we Find the Reason of the failure and put Corrective and Preventive Actions in place, the intent being never to witness the same failure repeated.

5 WHY Methodology has been successfully used over the years to do such RCA. Let us understand how to use the methodology with examples –

1. Very simply put, it means that the analyst has to Ask ‘Why?’ Five Times to find the root cause of the mishappening. It is historically observed that the root cause can be most certainly found by the time we ask the 5th time ‘Why’ to every answer we got for the previous ‘Why’s’.       Many a time, we get to the root cause at 3rd or 4th Why also depending upon the complexity of the issue. 

2. Let us understand this with a couple of examples –

 Example 1

 The Store worker has observed a fire in the Store-room

Why 1: Why did the incident occur?

Ans:     On proper examination of the area, there seems to be a short-circuit in the electricity board

Why 2: Why did the short-circuit occur?

Ans:     Because the wires were hanging loose with inadequate insulation

Why 3: We have a proper maintenance schedule for the electrician. Why were the wires hanging loose?

Ans:     On investigation, it was found that the electrician was absent on the scheduled day of maintenance and on resuming duty the next day, he missed looking at the job of the previous day

Why 4: Why did he miss the schedule? Why was he absent?

Ans:     He was over-worked during the planned maintenance and went home after doing 36 hours of duty at a stretch. There is no robust process of supervision or work instruction that tells him to check the previous day's pendency. He safely assumed that someone else would have attended in his absence.

Why 5: Why was he over-worked? Do we not have proper staffing in different shifts of operations?

Ans:     We have been managing with only one electrician for 3-shifts operation and many times, he needs to stay back and do overtime.

Did you notice that we found quite a few actionable points by the time we asked the 5th time ‘Why’

The possible Corrective and Preventive actions could be :

i) Appoint at least two more electricians (one on sub-contract and one on rolls) so that one person doesn’t need to work for more than 12 hours in a day. In case of any absence or emergency, call the sub-contracted electrician on need-basis.

ii) Put up a Work Instruction board in the maintenance room for the electrician to check at least the previous three days of completion before attending to the current day’s work.

iii) Add the responsibility of checking and signing the maintenance schedule daily before leaving, to the supervisor’s (maintenance manager) Key Performance Indicators.

Example 2

 The Store worker has observed a fire in the Store-room

Why 1: Why did the incident occur?

Ans:     On proper examination of the area, a burnt match stick was found in the room near the fire point

Why 2: Why was that match stick found in the sensitive area?

Ans:     Because one of the casual workers went for a smoke in that area. The guard did not stop the worker from entering into the restricted area

Why 3: Why did the worker leave for smoking?

Ans:     He has been like that and had a habit of leaving his assigned job for one reason or the other. His plea was that no one told him before that smoking in the area is prohibited. The CCTV camera shows that he leaves his work-station at least 4 to 5 times in a day and takes a long time to return back.

So, now we know the exact root cause. The possible Corrective and Preventive actions could be :

i) Remove that worker immediately from the job. Let it be an example for everyone for such indiscipline.

ii) Casual workers are not covered in our periodic safety and hygiene-related training. Include them from now on.

iii) Please instruct the store-room guard not to allow unauthorized entry in the restricted area

I hope you liked the concept and related examples.

Keep watching this space for more Tips!!

-Ajay Garg; Email : [email protected]