6 steps beyond the 5 Whys - AMMJ

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 what’s 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 can’t 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 investigator’s current
knowledge – you can’t find causes for things
you don’t already know
• Lack of support to help the investigator to ask
the right “why” questions
• Results aren’t 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 you’ll 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. Don’t 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
• Don’t 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 you’ll
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 people’s 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 won’t 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 don’t have to be the subject matter expert, so don’t
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
• Don’t 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 don’t 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
you’ve 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 Why’s,
let’s 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)
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.
With management’s 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)

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
Primary Effect
Delay in train loading
Caused by
Condition
Conveyor loads the train
Condition
Only 1 Loading Conveyor
Caused by
Caused by
STOP
STOP
Condition
6 hours to replace
drive motor
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
Caused by
STOP
Action
Motor was overloaded
Caused by
Action
Bearing seized
Condition
Seized bearing overloads
motor
Caused by
Caused by
Condition
Motor has overload
protection
Caused by
STOP
Primary Effect
Delay in train loading
Caused by
Condition
Conveyor loads the train
Condition
Only 1 Loading Conveyor
Caused by
Caused by
STOP
STOP
Condition
6 hours to replace
drive motor
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.

Let’s explore further on why the bearing seized by adding to the existing chart.
Primary Effect
Bearing seized
Caused by
Action
Metal welded together
Condition
welding seizes
the bearing
Caused
by
STOP
Caused by
Action
Temperature exceeded
melting point
Condition
Metal melting point “X”
Caused
by
STOP
Caused by
STOP
Caused by
Action
Bearing was operating
Condition
High friction in bearing
Condition
Didn’t trip out
Caused by
?
Caused by
Action
Metal expansion
in bearing
Condition
Minimal clearnace
in bearing
Caused by
STOP
Caused by
Action
High heat generated
Condition
Metal expands with heat
Caused by
STOP
Caused by
STOP
Caused by
Action
Bearing operating
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 Why’s 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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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 Analysis TM 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
Analysis TM 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
Analysis TM method for more complex problems. The Apollo Root Cause
Analysis TM 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 organisation’s needs.
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