root causeTo find the root cause of problems and bring order to your business, you must “peel the onion.” Triumph systematically, using the Five W’s – WHO, WHAT, WHEN, WHERE and WHY.

In journalism, those Five W’s make up the basic formula for telling the “full” story of an event. Some in lean management circles believe that, to find the root cause of a problem, you need to ask WHY at least five times. As we built the systems for our company, we referred to finding the root cause as “peeling the onion.”

As an onion has many layers that cover its core, problems in your business such as recurring errors or bottlenecks can be hidden. You will find them under layers of chaos, assumptions, poor planning, neglect, bad training, etc.  To get to the root cause of a recurring problem, those undesirable layers need to be peeled away, one-by-one.

WHY is a great tool for finding real solutions! You might be surprised how many people never ask WHY, and just continue to live with the problem. The advantage of asking WHY is simple. You don’t have to fill out charts or spreadsheets to find the root cause; the full story.

As a business owner, you have no doubt discovered that, in dealing with some people (the WHO), you will encounter push-back. The closer you come to exposing the root cause of a problem, the more pain you will seem to stir up.

Sometimes getting to the truth of an issue can be emotional, so asking the right WHY question takes practice and patience. However, if you’re going to fix the problems in your business permanently, you have to risk stepping on some toes in order to lead.

Example of “Peeling the Onion” Using the Five W’s

  • A customer has called to report an error and is rejecting a job due to inconsistent color.

When an error or bottleneck (non-conforming event) occurs in your business, the first thing that needs to be determined is WHAT happened. Next, the problem should be logged into a database so, after you correct it in the short term, the problem is not forgotten and swept under the rug.

  • WHAT ― The job was printed with inconsistent color

Next, determine WHEN the non-conforming event happened. This is very important! Your company should have a written policy about informing customers of any problems with your product within a certain amount of time, in order to be under warranty. You wouldn’t want a customer calling six months after a job was printed expecting a refund.

  • WHEN ― For this example, the job printed with inconsistent color happened five days ago.

Then, determine WHERE the non-conforming event took place in order to identify the process that needs to be corrected permanently.

  • WHERE ― The job with inconsistent color was printed in the press-room on the six-color press.

Next, determine WHO was involved in the non-conforming event. In many cases, there will be more than one person involved

  • WHO ― The person who operated the six-color press, and produced the job with inconsistent color.

Now that you have the WHO, it’s time to break out the WHY tool.  Meet with those who were involved in the error and start peeling the onion further.


Example conversation:

Administrator:    WHY did you have inconsistent color when producing the job?

Press Operator:   I was having a problem with the water and ink balance on the press.

Administrator:    WHY were you having that problem?

Press Operator:   The ink and water rollers need to be adjusted; many are worn and need to be changed.

Administrator:    WHY didn’t you stop the press, adjust the rollers and change out the ones that were too worn to be adjusted?
In the above example, the root cause SEEMS to be found in the second WHY.

However, if you keep asking WHY, you may discover…

  • The operator wasn’t given sufficient time to adjust rollers, or
  • The problem was due to pressure to get the work out, or
  • There was no Preventative Maintenance System in place.

Once you have identified the root cause of an issue, it’s time to implement a written interactive system/process to prevent this NON-CONFORMANCE from reoccurring. For example, a quality control checklist, daily routine checklist or a preventive maintenance checklists.

Finding the Root Cause of any Non-Conformance systematically is also known as CAPA Corrective Action – Preventive Action. We refer to this as the System Buster Locator.  In fact, this is the “secret-sauce” of TQM-Total Quality Management. In other words, the Continual Improvement  Process System!

Did I mention? Great Systems Work?

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