The Five Why’s Perspective

It’s mid-afternoon, an hour before the shift changes at a manufacturing plant, and I’m the foreman. I’m walking through the plant, giving a tour to a friend who happens to be a systems thinker. Suddenly, I see a pool of oil on the floor. So I grab the nearest member of the assembly line crew:

“Hey! There’s oil on the floor! For Pete’s sake, somebody could slip in that! Clean it up”

When I’m finished, my systems thinking friend breaks in with a quiet question: “Why is there oil on the floor?”

“Yeah,” I repeat to the crew member. “How’d the oil get on the floor?”

The crew member replies, “Well, the gabungie’s leaking.” All of us automatically look up. Sure enough, there’s a visible leak up there in the gabungie.

“Oh, okay,” I sigh. “Well, clean up the oil and get the gabungie fixed right away.”

My friend pulls me aside and murmurs, “But why is the gabungie broken?”

I say, “Yeah, well, the ga-” and turn to the crew member. “Why is the gabungie broken?”

“The gaskets are defective,” is the reply.

“Oh well, then, look,” I say. “Here. Clean the oil up, fix the gabungie and, uh, do something about the gaskets!”

My friend adds: “And why are the gaskets defective?”

“Yeah,” I say. “Just out of curiosity, how come we got defective gaskets in the gabungie?”

The shop floor crew member says, “Well, we were told that purchasing got a great deal on those gaskets.”

I can see my friend start to open his mouth, but this time I get there first. ‘Why did purchasing get such a great deal?”

“How should I know?” says the crew member, wandering off to find a mop and bucket.

My friend and I go back to my office and make some phone calls. It turns out that we have a two-year-old policy in the company that encourages purchasing at the lowest price. Hence the defective gaskets—of which there is a five-year supply—along with the leaking gabungie and the pool of oil.

In addition, this policy is probably causing other problems throughout the organization, not closely related in time or space to the root “cause.”

Rick Ross – From the “Fifth Discipline Fieldbook” by Peter Senge (p.108-109)

Share a situation you have experienced where the “five whys” were not asked and the wrong problem was being addressed. Include detail such as:

Describe the situation.
How would the “five whys” be used in this situation?
How was it resolved?
Was the root problem addressed?
What could be done differently?
Is there literature that discusses this situation and how it could be resolved?
How does “just culture” philosophy come into play in your situation?