Transcript
Page 1: The Five Whys - Are We Doing it Wrong?

!"#$%&'#$(")*$

!"#$%&'#()*+',#-./#0).1*-.2.#$-"#

Page 2: The Five Whys - Are We Doing it Wrong?

+,-../01201$345$6/.2/%7$

(#$*"89:;$<#$=>?#@9:$A8$B8A$*&CD:)$>==#DA$EFA"$+#BA9?)$.#>B$=8B=#DA*$G9*A$<#=>9*#$A"#)$HA$89?$D?#=8B=#DI8B*J$$(#K'#$:#>?B#;$>$:8A$*&B=#$A"#B$>B;$&A$:88L*$:&L#$M#$C>)$">'#$C&*9B;#?*A88;$*8C#$.#>B$=8B=#DA*J$$!"#$KN$(")*K$C>)$<#$>B$#O>CD:#J$

P$

3#

Page 3: The Five Whys - Are We Doing it Wrong?

+30Q/0!230-.$./-0$(27R3S$7-T7JJJ$

!"#$N$(")*$&*$>B$&A#?>I'#$U9#*I8BV>*L&BW$A#="B&U9#$9*#;$A8$#OD:8?#$A"#$=>9*#V>B;V#X#=A$?#:>I8B*"&D*$9B;#?:)&BW$>$D>?I=9:>?$D?8<:#CJ$!"#$D?&C>?)$W8>:$8@$A"#$A#="B&U9#$&*$A8$;#A#?C&B#$A"#$?88A$=>9*#$8@$>$;#@#=A$8?$D?8<:#CJ$$!"#$%&'()*$+,#$-./$01/&$%)2$%)&+/3()*$(4$/%5,$01/6$+/$5%)$*/4$4,/$4,/$3/%7$5%8&/$9:$4,/$;39<7/1=!$$$45-%%6+%#7+.)8#95)")*-#:,)/;62).#<"1*'=8#>?#@A#

B#

Page 4: The Five Whys - Are We Doing it Wrong?

!3R-T$!,/7/$7!-!/S/0!7$.33Y$S35/$.2Y/$-!!5-+!2Q/$(27,%4.$!,20Y201$

!"#$%&'()*$+,#$-./$01/&$%)2$%)&+/3()*$(4$/%5,$01/6$+/$5%)$*/4$4,/$4,/$3/%7$5%8&/$9:$4,/$;39<7/1=!$$$$45-%%6+%#7+.)#

!"#$N$(")*$=8B=#DA$>B;$A"#$U98A#$@?8C$3"B8$>?#$>DD#>:&BW$A8$89?$<?>&B*Z$M"&="$">'#$>$B>A9?>:$9?W#$A8$M>BA$=#?A>&BA)Z$#'#B$M"#B$&A$&*$B8A$A"#?#J$$%&B;&BW$A"#$?88A$=>9*#$8@$>$D?8<:#C$&*$A)D&=>::)$)94$D8**&<:#$A"?89W"$;&*=9**&8BZ$<?>&B*A8?C&BWZ$:8W&=$>B;$?#>*8BJ$T89$">'#$A8$#OD#?&C#BA$>B;$:#>?B$)89?$M>)$A8$W?#>A#?$LB8M:#;W#$[$9B;#?*A>B;&BWJ$$-A$<#*AZ$>*L&BW$A"#$N$(")*$&*$>$<?>&B*A8?C&BW$A#="B&U9#Z$B8A$>$D?8<:#CV*8:'&BW$A#="B&U9#J$$!"#)$;8BKA$?#'#>:$>B)A"&BW$<#)8B;$M">A$M#$>:?#>;)$A"&BL$M#$LB8MJ#

C#

Page 5: The Five Whys - Are We Doing it Wrong?

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

D#

Page 6: The Five Whys - Are We Doing it Wrong?

!,/$FKB?GKLMN$LO$PELHM?NQ?$

!"#$!"?#*"8:;$8@$YB8M:#;W#$&*$A"#$D8&BA$>A$M"&="$)89$">'#$B8$@>=A*$>B;$;>A>$>B;$*A>?A$W9#**&BWJ$!"#$!"?#*"8:;$8@$YB8M:#;W#$&*$;&^=9:A$A8$*D8A$<#=>9*#$M#$;8B_A$?#>:&`#$A">A$89?$<?>&B$&*$>9A8C>I=>::)$H::&BW$&B$89?$LB8M:#;W#$W>D*J$

E#

Next Target

ConditionCurrent

KnowledgeThreshold

??

?

Page 7: The Five Whys - Are We Doing it Wrong?

Cause 1 Cause 2 Cause 3 Cause 4

Why? Why? Why? Why? Why?

Cause 5

Are you sure? Can you test it?

Where are the facts?

-7Y201$!,/$N$(,T7$20$-$7201./$72!!201$3%!/0$R3/70K!$S-Y/$7/07/$

Are you sure? Can you test it?

Where are the facts?

A#

Page 8: The Five Whys - Are We Doing it Wrong?

6/+-47/$!,/$(-T$!3$-$!-51/!$+30R2!230$27$03!$-$7!5-21,!$.20/$

F#

YB8M:#;W#$!"?#*"8:;a$$]8**&<:#$=>9*#*$A#*A#;$8B:)$A8$"#?#b$'&>$@>=A*Z$;>A>$>B;$D?&8?$#OD#?&C#BA*J$

Condition Current

Target Condition

0-;1'#B#

0-;1'#3#

0-;1'#@#

0-;1'#B?3#

0-;1'#B?E#

0-;1'#B?D#

0-;1'#B?@# 0-;1'#B?B#0-;1'#B?C#

G+"#H3# 7I1*-6J'#@#

G+"#HB#

7I1*-6J'#3#G+"#HB#

Page 9: The Five Whys - Are We Doing it Wrong?

!(3$R2%%/5/0!$S20R7/!7$S-T$]53R4+/$!(3$R2%%/5/0!$20!/5]5/!-!2307$

K%./#="#!"?#*"8:;$8@$YB8M:#;W#8#L+','#M#.''/#*)#/)#*+'#.'N*#'N>',%='.*#*)#I'#-IJ'#*)#1''#O;,*+',##

]9?D8*#$8@$>*L&BW$A"#$N$(,T7#

-$]#?*8B$M"8#;&*:&L#*$9B=#?A>&BA)c#

P'*#*)#,))*#6-;1'#)O#-#>,)IJ'=#

-$D#?*8B$M"8#&*$3Y$M&A"$9B=#?A>&BA)c#

Q#

Page 10: The Five Whys - Are We Doing it Wrong?

@R#

Page 11: The Five Whys - Are We Doing it Wrong?

The scientific process can only confirm or refute; it doesn't define or limit what is possible ahead of time.

@@#

S;)*'#O,)=#!"#$%&'$()$*+,#-+##I"#T'..%1#5,;=IJ'#

Page 12: The Five Whys - Are We Doing it Wrong?

%35$R/!-2.$30$,3($!3$+30R4+!$/d]/52S/0!7$7//$!,27$7.2R/7,-5/$

@3#

R7(5'$9)$4,/$7()'$93$(778&43%09)$</79+$

LLL?1J%/'1+-,'?.'*U=%&'ABCU%&6&V>,-626'V&%*#