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5 Whys Folklore: The Truth Behind a Monumental Mystery

AUGUST 19, 2014 BY JOEL A. GROSS

When you think of the great individuals in lean history, what names come to mind? W. Edwards Deming. Taiichi Ohno. Shigeo Shingo. Don Messersmith. Oh, you’ve never heard of Don Messersmith? Perhaps, you’re not familiar with the name, but I can almost guarantee that you are familiar with his work.

Don Messermith is an esteemed professor emeritus at the University of Maryland. His accomplishments in the field of etymology – the scientific study of insects – are many, as evidenced by the extensive list of distinguished titles, prestigious awards, and publications that bear his name. But among his comprehensive catalog of contributions, one study in particular stands out above the rest.

Although the work predated the Google search by nearly a decade, and despite never warranting an official publication, there are more than 140,000 pages on the internet which reference the study. As a matter of fact, it’s quite likely that there is only one surviving copy of the work still in existence today. So, why should we care about some little-known, unpublished report from a study on insect behavior performed almost 25 years ago? Because sitting in a file folder in the desk drawer of Don Messersmith resides a report on perhaps the single, most famous problem ever solved:

Messersmith, Donald H. 1993. Lincoln Memorial Lighting and Midge Study . Unpublished report prepared for the National Park Service. CX-2000-1-0014. N.p

If you’ve ever taken a course on the topic of scientific problem solving, it’s highly likely that you’ve heard this tale of crumbling monuments, foul birds, swarming insects and simple solutions. Although the subjects of the study were decidedly of the two-, six-and eight-legged variety, the work has become the quintessential case study on the application of the “5-whys”.

A Monumental Mystery

The 5-whys is a method of root cause analysis in which the learner repeatedly asks, “why?” in order to drill down from higher-level symptoms to the underlying root cause(s) of a problem. So critical is this line of logic to lean thinking that Taiichi Ohno once described the method as “the basis of Toyota’s scientific approach . . . by repeating why five times, the nature of the problem as well as its solution becomes clear.”

As any parent can attest, children are remarkably astute in their ability to repeatedly ask why when they wish to learn about their world. The grand lesson of life is the discovery that all things in the universe are what they are “because mommy said so!” It is likely this realization that ends our fascination with the word “why” at an early age. This is why, as an instructor teaching the technique to adults, it helps to have a strong example to restore the credibility of repeatedly asking why in the context of problem solving.

Enter the work of Don Messersmith, whose study on the lighting of the memorials in Washington D. C. has become cannon to the teaching of the 5-whys method. Due in part to the scarcity of the source document, many different versions of the tale exist today. And while you may have learned a slightly different version, the general details of the story are as follows:

Problem: One of the monuments in Washington D.C. is deteriorating.

Why #1 – Why is the monument deteriorating?

Because harsh chemicals are frequently used to clean the monument.

Why #2 – Why are harsh chemicals needed?

To clean off the large number of bird droppings on the monument.

Why #3 – Why are there a large number of bird droppings on the monument?

Because the large population of spiders in and around the monument are a food source to the local birds

Why #4 – Why is there a large population of spiders in and around the monument?

Because vast swarms of insects, on which the spiders feed, are drawn to the monument at dusk.

Why #5 – Why are swarms of insects drawn to the monument at dusk?

Because the lighting of the monument in the evening attracts the local insects.

Solution: Change how the monument is illuminated in the evening to prevent attraction of swarming insects.

I use this example frequently in my own classes, and, because of its effectiveness and its ability to engage, it has become my absolute favorite slide to deliver. The story drives home a powerful point: deep understanding of the root causes of our problems yields simpler, more effective, and less costly solutions. In fact, the lesson is so effective, that many learners are cynical as to its validity. After years of questions from students, I set out to research the topic and to separate fact from fiction in the tale of the eroding monuments. In doing so, I had the great honor of corresponding directly with Dr. Messersmith to review the details of his work first-hand.

What should not be surprising is that the story is not entirely true-to-life, but neither should it be considered a work of fiction. Some trivial points have simply been confused over time, but some not-so-trivial details have unfortunately been omitted from the retelling of the tale so as to create a simpler, more plausible study. In this case, truth is indeed better than fiction, and when added back into the fold, the missing pieces of the story actually paint a much more robust and complete picture of the nature and complexity of real-world problem solving.

Debunking the 5-Whys Folklore

The following discussion of the myths associated with the 5 whys case study are based on available source documents (links provided where possible) and on direct correspondence with Dr. Messersmith himself.

Myth #1 – Whose Monument is it, Anyway?

The first bit of mystery surrounding the tale is the exact monument that was experiencing the deterioration. Some versions specify the Washington Monument , some the Lincoln Memorial and others the Jefferson Memorial . The facts are that the case study is relevant to both the Jefferson and the Lincoln memorials, but not specifically the Washington Monument. As detailed in this article from the Associate Press in 1989, a group of private consultants were hired by the National Park Service (to the tune of $2 million) to perform a year-long study of the deterioration of the Lincoln Memorial and the Jefferson Memorial.

In April of 1990, the consultants published a report which found that “the increasingly toxic effects of nature” had accelerated the erosion of the monuments and that immediate steps were required to address “very serious structural problems”. A Park Service representative responded to the findings by assuring that “both memorials are in excellent shape overall” and that there was “absolutely no danger to the public”. Less than one month later in May of 1990, a 50 lb. block of marble fell from the volute on the top of a column in the Jefferson memorial. Thankfully, no one was injured, and major repair and rehabilitation projects were subsequently initiated to address the deficiencies in both monuments.

Myth #2 – Cleaning Chemicals as the Culprit

In most versions of the story, the erosion and degradation of the monuments were attributed to the use of the harsh chemicals needed to remove the bird droppings from the monument’s surfaces. This explanation falls short of the complete truth in two ways.

First, the act of cleaning was cited only as one contributing factor among many – like acid rain, water seepage, air pollution and littering tourists – to the damage observed on the memorials.

Second, cleaning chemicals were not causing the lion’s share of the deterioration. Rather, per the consultant’s report , it was actually the large volume of water applied during the cleaning process that was found to pose the greatest threat to the marble and limestone buildings. As later detailed in this government investigation into the falling chunk of the Jefferson Memorial, when water seeps into inclusions in marble and limestone, it drives further propagation of the cracks, which may result in structural deficiencies.

Although very little could be done to reduce the volume of exterior rainwater to which the memorials were exposed, measures focused on reducing the volume of water used internally within the monuments as part of the cleaning process. The Associated Press article from 1990 stated that the Park Service had “dramatically reduced the volume of water used to wash the monuments”, even going so far to to say that they would need to “educate the public to understand that these buildings may not appear as pristine white in the future as they once did” because of the reduction in water used to clean them.

Myth #3 – Cleaning was for the Birds

It is true, the large prevalence of bird droppings – specifically from starlings and sparrows ( not pigeons ) – did contribute to the need for a daily scrubbing of both monuments. However, the bulk of the mess was not cause by a bird byproduct. As the story goes, midges ( not gnats ) swarmed to the river-side monuments because the lights replicated their preferred, dusky mating conditions.

Rather than doing the deed over the water, the lights drew them inland in vast swarms where they splattered against the monument walls to deposit their eggs in the form of dark – not to mention hard-to-clean – masses. Although the prevalence insects did invite a large population of spiders, which in turn brought the starlings and sparrows, it was the midges themselves that necessitated the bulk of the bathing.

Myth #4 – Shedding Some Light on the Solution

When it came to the lighting of the monument as a solution to the problem of deterioration, there are really two separate myths at play.

First, the true impact of the story comes from the belief a simple, low-cost solutions can effectively prevent recurrence of major problems, when more-complicated and more costly alternatives would likely fail to do so. For this particular problem, however, this is not the case. It must be noted that the suggested lighting change was just one of many actions taken in response to the larger problem. In fact, the list of improvements took more than five years and $25 million to complete , and included a detailed analytical characterization of every single piece of stone in both monuments.

Second, (and this is where the whole story becomes very interesting), delaying the lighting at night was indeed successful in reducing the number of midges AND there was the added bonus of money saved on energy costs, BUT YET the improvement still was not implemented long-term. Yes, you read that correctly. Allow me to elaborate.

In early 1990, Park Service officials agreed to a six-week pilot program during which the lights around the memorials were turned on one hour after sunset on Mondays, Wednesdays and Fridays. Don Messersmith and a team of students proceeded to count the number of midges on the monuments on these nights and compare them to the nights in which the lights were turned on before sun down. After 6 weeks, and as predicted by Dr. Messersmith, the change in the timing of the lights resulted in an 85% reduction in midge infestation. Everyone initially seemed pleased with the results of the pilot study. . . well, almost everyone.

The Jefferson and the Lincoln Memorials sit along the banks of the Potomac River, which creates quite a picturesque setting for photographers to apply their craft. The change in the timing of the lights drew ire from those seeking to capture breathtaking images of an illuminated memorial against the backdrop of a sunset blazing across the river. As of this January 1992 article , Park Service officials were still evaluating whether to pursue a permanent change to the timing of the lights, but by September of 1995 , the countermeasure was no longer under consideration due to the overwhelming number of complaints from photo-seeking tourists.

The article continues to detail the actions that were taken over the subsequent FIVE YEARS(!!!) to dissuade birds, spiders and midges from congregating on the memorials, which included the installation of wires, metal spikes, netting and clear plastic. But without addressing the underlying root cause of the problem (the timing of the lights), these actions had little to no impact on easing the amount of cleaning required.

Unfortunately, at this point, in September of 1995, the trail of new information goes cold . . .

The Moral of the Story

Like all good stories, there is much to be learned from the tale of the Lincoln and Jefferson memorials. But without knowing the whole story, it’s difficult to say exactly what the most important lesson is. Maybe it’s the value of that a thorough understanding of cause and effect has on the efficiency and effectiveness of solutions. Maybe it’s the difficulty of solving complex problems under real-world conditions. Perhaps, however, it’s the importance of hope. Yes . . . hope . Because if these recent images of the Lincoln Memorial and the Jefferson Memorial at sunset are any indication, then there might just be hope for my government yet.

The KaiZone would like to formally thank Dr. Don Messersmith for taking the time out of his busy schedule to contribute to this piece. This piece would not have been possible without his input.

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Root Cause Analysis – We have to do better than Five Whys!

(Photo: Ad Meskens)

If you’ve ever had training on root cause analysis (RCA) you will almost certainly have learnt about Five Whys. Keep asking ‘why’ five times until you get to the root cause. The most famous example is of the Lincoln Memorial in Washington. The summary of this Five Whys example is reproduced below from an article by Joel A Gross:

Problem: The Lincoln Memorial in Washington D.C. is deteriorating.

Why #1 – Why is the monument deteriorating? Because harsh chemicals are frequently used to clean the monument.

Why #2 – Why are harsh chemicals needed? To clean off the large number of bird droppings on the monument.

Why #3 – Why are there a large number of bird droppings on the monument? Because the large population of spiders in and around the monument are a food source to the local birds

Why #4 – Why is there a large population of spiders in and around the monument? Because vast swarms of insects, on which the spiders feed, are drawn to the monument at dusk.

Why #5 – Why are swarms of insects drawn to the monument at dusk? Because the lighting of the monument in the evening attracts the local insects.

Solution: Change how the monument is illuminated in the evening to prevent attraction of swarming insects

This example is easy to understand and seems to demonstrate the benefit of the approach of Five Whys. Five Whys is simple but suffers from at least two significant flaws – i) it is not repeatable and ii) it does not use all available information.

Different people will answer the why questions differently and their responses will take them to a different conclusion. For example to Why #2 “Why are harsh chemicals needed?”, the response might be “Because the bird droppings are difficult to remove with just soap and water”. This leads to Why #3 of “Why are bird droppings difficult to remove with just soap and water?” and you can see that the conclusion (“root cause”) will end up being very different. The approach is very dependent on the individuals involved and is not repeatable.

Other questions that would be really beneficial to ask but would not be asked using a Five Why approach are:

When did the problem start? Armed with the answer to this might have helped link the timing with when the lighting timing was changed.
How many other monuments have this problem? If other monuments do not have this problem then what is different? If other monuments have this problem then what is the same? This line of questioning is, again, more likely to get to the lighting timing quickly and reliably because a monument without lighting and without the problem suggests the lighting might have something to do with the cause.

In my last post I described a hypothetical situation of a vaccine trial where subjects had received expired vaccine. If we use the Five Whys approach, it might go something like:

Why did subjects receive expired vaccine? Because an expired batch was administered at several sites; Why was an expired batch administered at several sites? Because the pharmacists didn’t check the expiry date; Why didn’t the pharmacists check the expiry date? Here we get stuck because we don’t know. So maybe we could try again.

Why did subjects receive expired vaccine? Because an expired batch was administered at several sites; Why was an expired batch administered at several sites? Because the expired batch wasn’t quarantined. Why wasn’t the expired batch quarantined? Because sites didn’t carry out their regular check for expired vaccine. Why didn’t sites carry out their regular check for expired vaccine? Because they forget maybe? Or perhaps didn’t have a system in place? As I hope you can see, we really end up in guess work using Five Whys because we are not using all the available information. Information such as which sites had the problem and which didn’t? When did the problems occur? What is the process that ensures expired vaccine is not administered? How did that process fail?

Five Whys can be fitted to the problem once the cause is known but it is not a reliable method on its own to get to root cause. Why is definitely an important question in RCA. But it’s not the only question. To quote the author of ‘The Art of Problem Solving’, Edward Hodnett, “If you don’t ask the right questions, you don’t get the right answers. A question asked in the right way often points to its own answer. Asking questions is the ABC of diagnosis. Only the inquiring mind solves problems.”

Here are more of my blog posts on root cause analysis where I describe a better approach than Five Whys. Got questions or comments? Interested in training options? Contact me .

Note: it is worth reading Gross’s article as it reveals the truth behind this well-known scenario of Lincoln’s Memorial.

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12 thoughts on “Root Cause Analysis – We have to do better than Five Whys!”

This is why Lean Six Sigma seeks to validate the answer to “Why” with hypothesis tesying of the data. If you don’t know for certain the root cause, you need the Six Sigma side of things.

I agree that “the 5 whys” is just part of the problem solving approach. I’ve written about it here in these posts:

http://www.leanblog.org/2015/11/you-just-have-to-ask-why-five-times-lean-or-leanstartup-requires-more-than-that/

http://www.leanblog.org/2015/11/maybe-we-should-call-it-the-many-whys-instead-of-the-five-whys/

I agree with the author’s statements regarding 5-whys. However, since I work in the automotive industry, it is a common request from OEM’s to complete a 5-why. Utilizing my Six Sigma training, I try to define a problem statement answering the questions below. What? Where? When? How much? Answering these questions, usually scopes a problem fairly well.

I agree with all the comments from the point of being just one tool in the suite of LSS tools to use as you walk through the DMAIC process. Like in the story about the Lincoln Memorial, my thought always come back to the Control phase. The story is missing that element. To me the 5 Why’s get you somewhere just like a really busy fishbone diagram, but in the control phase you can monitor the results of the other efforts to see if rest of the process was fruitful.

I am somewhat of a traditionalist with regard to the use of the “5-Whys” method of cause investigation (notice that I used the term investigation vs. analysis). I will come back to discuss that distinction a bit later.

First, I refer to traditional as way of referring to the classic use of 5-whys to identify the “root cause”. In this context I think of it as the most basic, simple and practical way to identify the root cause that I know of. To arrive at this rationale one needs to apply a few basic assumptions, such as:

1. that the problem situation is empirical (in other words the situation can be observed) 2. that the situation is understood well enough to be able to “locate the point of cause” — use: “4 W’s & H” (the “PoC” is the point where the “direct cause” can be observed) 3. that it is understood that there is nothing sacred about the number ‘5’ in “5-Whys Cause Investigation” and that you ask as many whys as necessary to identify the root cause.

In my view, once these assumptions are accepted, it becomes fairly straight-forward to practically apply the use of the 5-why method effectively.

My experience suggests that most of us come-by our thinking about subjects such as this through what we learned and did at the different companies where we have worked. This certainly applies in my case. In fact, the company where I learned to use “5-Why Cause investigation” had a method of doing problem solving in empirical situations. It was called “Practical Problem Solving” based on a CA- PDCA model and it was to be applied in situations when causes could be observed. Therefore, 5-whys was used as a systematic approach to observing the process. As such, it was an investigating process in which you would need need to go and see; rather than an analyzing process, where you can sit at your desk and analyze data to postulate what the “direct cause” probably is (which is appropriate when one is dealing with a problem situation that is complex, in which the causes are in a “black box” and you cannot see the direct cause.

This briefly summarizes my justification for the “5-Whys” method of cause investigation. So, that’s my story and I’m sticking to it!:-) (I’m sticking to it at least until I am presented with a better mouse trap.)

Thanks for the opportunity to join into the dialog! I hope that it was understandable/relate-able, and that it adds something to the conversation. I’m counting on hearing some feedback — don’t hold back…

Very well stated. I have and will us the 5 Why (or more Why’s if needed) . I also you the PDCA, DMAIC, Fishbone, etc…. Some tools work better in some cases then others. Sometime I use two tool to valid the first one used, or a combination of tools. My basic believe is that the 5 Why is a good tool to teach people to “problem solve” (if you can teach that). I makes people ask question and think independently.

I believe there is some validity in the author’s critique of the 5-Whys method of finding the root cause, but it can and is a very useful tool to start on the journey to discovering and defining the actual root cause of a problem (Opportunity!). It can–and does—fall short if not used to its fullest extent, as discussed by some of the succeeding writers: It doesn’t have to STOP at just (5) whys, and there are several other LSS Tools in the toolkit to continue the transit to the Root Cause, such as a fishbone diagram as mentioned previously.

Just as you wouldn’t reach for a 9/16ths wrench to loosen a 3/4 bolt doing brake work on your car, you choose the appropriate tool for the job or task at hand. If the 3/4 bolts still couldn’t be loosened with the socket wrench and correctly-sized socket, you might choose a longer torque handle to expand on your ability to exert additional force on the offending bolt. And so on and so forth——-the key being you escalate your problem-solving efforts (and use of various tools) until the job is completed.

Brainstorming, fishbone diagram, controlled trials, and a small-scale proof-of-concept” can all be added to the basic 5-Whys Tool to arrive at concrete Root Cause conclusions—where appropriate.

The real key is don’t stop until you find the REAL root cause of a problem. Yes, it can—at times–make Management uncomfortable because the finger may point back to a bad decision that precipitated the issue, but I believe you will find the more thorough you are at tracing an opportunity back to the root cause, by taking the time and effort to correct it at the source, you may not only erase it forever, you may preempt a host of similar issues from ever popping up.

The problem with the 5 why’s is that it assumes there is a straight line to the root cause, what may work for simple problems, almost never does for complex ones. The major flaw is that it forgets the fact that the different components of any given systems are interralated. I always prefer a method where I can see those connections and found particular appealing the Current reality Tree, a TOC tool conceptually similar to the Fault Tree Analysis. I found the 5 why’s weak except for most of the rapid problem solving PDCA applications found on the floor in most companies that adopted Lean method. In this line of thought I am not a big fan of the fishbone analys either that basically follows the same principle of the 5 why’s however, aggravated because in many many cases people stopps at the first or second level and call it done, struggling to apply appropriate corrective actions in many pseudo root causes.

Great comments above – thanks!

One of the misconceptions I run in to is that the answers to the 5-Why’s questions is a single answer. For a complex problem or one that the root cause truly is not known, there may be several answers. Many of the softwares used in 5-Why analysis promote this by using a linear set of questions and answers. I encourage people to go back to pen and paper, whiteboards, etc. Branch off when you need to with the 5-Why’s. When it’s all said and done, a good 5-Why analysis transforms in to an ishikawa diagram that you can take multiple actions with!

In my experience 5 Why’s usually works well when used as a complement of other problem solving tools. This tools should include information complementing the problem to ensure that the questions asked are the right ones (or close to them). Something else that should be done is avoid asking questions by yourself. Do it in groups, diverse groups with people of involved areas in the problem and with different levels of experience; you’ll be surprise how many times the right questions are asked by people with less experience or close to GEMBA.

5 why’s generally for me is the last step after having developed a fishbone (Ishikawa chart) each end gets a 5 whys… there might more than one cause, or combination of causes. The fishbone helps keep more variables in mind making 5whys Lee’s subjective.

My issue with 5 why’s without: The Who, What, Where, When, How Much first are never more than educated guesses.

My 2nd issue with 5 why’s is, there are more than 1 corrective actions, which if not thought out in the same manner as a 5 why is a “trap” and get ignored.

EE slipped and fell OSHA recordable.

Why: The floor was slippery. Why: The floor was wet. Why: Another EE mopped with improper chemical. Why: EE mopping didn’t dispense the correct chemical.

Why: The floor was wet. Why: The EE didn’t see the wet floor sign. Why: The EE wasn’t paying attention.

Why: The EE wasn’t wearing slip-resistant shoes. Why: The EE forgot to change shoes. Why: EE was rushed coming in to work.

In all cases, there is a process or a behavioral root cause that needs countermeasures put in place, but forced into 1 set of 5 why’s, the others are merely being prioritized as educated guess and may/may not be addressed. Depends on the skill set of the individual completing the 5-why.

Comments are closed.

The Five Whys Approach To Finding Root Causes

The Five Whys is an iterative interrogation process that’s primarily used to identify the root cause to a problem. It works by simply asking the question “Why?” repeatedly until you find a root cause. It was made famous by Toyota. Summary by The World of Work Project

The five whys has an important role to play in problem solving . It is used within the A3 Thinking approach to problem solving.

When looking for effective long term solutions to problems, it’s essential to understand the actual root causes as to why something is happening. Five Whys analysis is a process to identify these root cause. It works by getting people to repeatedly ask the question why. Each why drills down into each previous answer until they have reached the root cause.

Many examples of the five whys in action are available on the internet. For our example, we’ve chosen to focus on the Jefferson Memorial, in Washington DC. The story, which may be apocryphal, goes that the memorial was eroding very quickly, meaning it was becoming expensive to maintain.

The five whys method was used to identify the root cause to this problem. The iterative process went like this:

Why 1: Why was the Memorial eroding so quickly?

Because high powered sprayers were being used to clean the monument every two weeks.

If this was as far as the questioning process went, the solution would be to look for a new cleaning solution. Or perhaps looking to change the chemicals.

Why 2: Why was the monument being spray cleaned every two weeks?

Because there was a large amount of bird droppings on it.

If this was as far as the questioning process went, the solution would be to perhaps find a new way to remove the bird droppings. Or perhaps to find a way to prevent the birds fouling the monument, maybe with netting.

Why 3: Why were there so many birds at the monument?

Because the birds were all attracted to the monument by the large number of spiders that resided there.

If this was as far as the questioning process went, the solution would be to perhaps find a way of removing the spiders. Pesticide could be an option.

Why 4: Why were there so many spiders at the monument?

Because the spiders were attracted by the large number of insects there for them to feed on. We know it’s starting to sound like the old lady who swallowed a fly. but stick with it!

If this was as far as the questioning process went, the solution would be to perhaps find a way of removing the insects. Again, pesticide could be an option.

Why 5: Why were there so many insects at the monument?

Because the insects were attracted by the high powered lights that were turned on around dusk.

Having made it all the way through the five whys, investigators found a root cause: the lights, and specifically the time they were turned on.

The solution that ended up being implemented was to turn the lights on a little bit later, after most of the insects had gone to sleep for the night.

The Outcome

This solution was much simpler and cheaper than the other solutions that would have been implemented had the five whys not been fully used.

As a result of turning the lights on later, they attracted far fewer insects, which reduced the spider population, which reduced the bird population, which reduced the bird fouling, which meant the monument needed to be cleaned less often, and with less corrosive cleaning agents. A side effect of the solution was a saving in electricity costs as well.

Interestingly, the same problem of deterioration is being faced by the Taj Mahal, and similar root cause explorations have been undertaken there.

Learning More

Thinking about what we do from different perspectives and with others is very helpful for decision making. Tools like the reframing matrix process or hackathons can help us do this.

Part of the reason we’re not great at problem solving is that we all have thinking habits and cognitive biases that restrict our creativity. In particular, these decision making biases often lead us towards bad (or irrational) decisions. And sometimes we make decisions just because ISLAGIATT …

Solving problems as a team using things like The A3 Problem Solving Process improves our problem solving. Similarly, an ease/benefit matrix helps us decide what to focus on in the first place. When we are actually working on things like this in groups it’s useful to use techniques like silent brainstorming to get the best results.

To learn more about creativity, innovation and problem solving, you might enjoy the third of our three podcasts specifically on these topics. It focuses mainly on cognitive processes:

The World of Work Project View

The five whys is a fine tool to know about and a good rule of thumb to follow.

Of course, you don’t need to do exactly five iterations to find the root cause. Sometimes you need more and sometimes less. All you really need to know is the key point: you should keep drilling into things and not take the first possible solution that you see.

Regarding the various examples that exist to demonstrate the five whys, we’re not really sure that they’re true. They could all be apocryphal, but even if they are they are nice and they help bring the concept to life.

From our experience in the world of business, this method is used to some extent . But it could be used more effectively. It’s important to keep drilling into problems if you’re to really find their root cause, and this may not be being done as well as it could be.

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The World of Work Project: The Five Whys Approach To Finding Root Causes

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5 Whys and the Monumental Mystery

June 23, 2020 by: ed wells, rca training.

Because powerful chemicals are frequently used to clean the monument.
To clean off the excessive volume of bird droppings on the monument.
Because the large population of spiders in and around the monument are a food source to the local birds.
Because vast swarms of flying insects, on which the spiders feed, are drawn to the monument at dusk.
Because the lighting of the monument in the evening attracts the local insects.

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Root Cause Analysis with 5 Whys Technique (With Examples)

By Sebastian Traeger

Updated: March 21, 2024

Reading Time: 7 minutes

What Is the 5 Whys Technique?

Example of the 5 whys technique, how to conduct a 5 whys analysis in 5 steps, when to use a 5 whys analysis, using 5 whys template, tips for mastering the 5 whys technique, frequently asked questions about 5 whys.

With over two decades in business – spanning strategy consulting, tech startups and executive leadership – I am committed to helping your organization thrive.

At Reliability, we’re on a mission to help enhance strategic decision-making and operational excellence through the power of Root Cause Analysis, and I hope this article will be helpful!

Our goal is to help you better understand 5 whys techniques by offering insights and practical tips based on years of experience. Whether you’re new to doing RCAs or a seasoned pro, we trust this will be useful in your journey towards working hard and working smart.

The 5 Whys Technique is like peeling an onion – it helps you uncover the underlying reasons behind a problem, layer by layer. By repeatedly asking “why” at least five times, this method digs deep to reveal the root cause of an issue. It’s a simple yet powerful problem-solving approach that aims to get to the heart of the matter rather than just addressing surface-level symptoms.

5 Whys Technique: A method that involves iteratively asking “why” five times to unveil the fundamental cause of a problem.

In essence, the 5 Whys Technique is not just about fixing what’s broken on the surface; it’s about understanding and addressing the deeper issues that lead to problems in the first place.

The 5 Whys Technique is like a detective, uncovering the truth behind recurring problems. Let’s take a look at how this method works in two different scenarios.

Case Study: Manufacturing Defects

Imagine a company that keeps encountering the same manufacturing defects despite various attempts to fix them. By using the 5 Whys Technique, they discovered that the defects were not caused by faulty machinery, as previously assumed, but rather by human error due to unclear operating instructions. This realization led to improved training procedures and clear work guidelines, ultimately eliminating the defects.

Application in Service Industry

Now, consider a service industry struggling with frequent customer complaints and service failures. Through the 5 Whys Technique, it was revealed that these issues stemmed from inadequate staffing levels during peak hours. By addressing this root cause, such as hiring additional staff or adjusting schedules, the service quality can significantly improve, leading to higher customer satisfaction.

These examples illustrate how the 5 Whys Technique can be applied across different sectors to identify and address underlying issues effectively.

Step 1: Identify the Problem

Before diving into a 5 Whys analysis, it’s crucial to clearly identify the problem or issue at hand . This step sets the stage for the entire process and ensures that the focus remains on addressing the right concern. Take the time to gather relevant data, observe patterns, and consult with team members or stakeholders to gain a comprehensive understanding of the problem.

Step 2: Ask ‘Why’ Five Times

Once the problem is clearly defined, it’s time to start peeling back the layers. The process involves asking “why” five times, not necessarily limited to five questions but enough to delve deeper into the underlying causes of the problem . Each “why” serves as a gateway to uncovering additional factors contributing to the issue. This iterative approach helps in identifying not just one cause, but multiple interconnected elements that may be at play.

By consistently probing deeper with each “why,” you can reveal hidden complexities and nuances that may have been overlooked initially. This method allows for a more thorough understanding of the situation, paving the way for effective solutions that address root causes rather than surface-level symptoms.

This structured approach encourages critical thinking and enables teams to move beyond quick fixes towards sustainable improvements.

The 5 Whys Technique is a versatile problem-solving approach that can be applied in various scenarios to uncover root causes and drive continuous improvement. Here are two key situations where the 5 Whys Analysis can be particularly beneficial:

Recurring Issues

The 5 Whys Technique is especially useful when dealing with recurring issues. Whether it’s a manufacturing defect that keeps resurfacing or a persistent customer complaint in the service industry, this method helps identify the underlying reasons behind these repetitive problems. By repeatedly asking “why,” it becomes possible to trace the issue back to its root cause, allowing for targeted solutions that prevent reoccurrence.

Process Improvement

Organizations constantly strive to enhance their processes and workflows for increased efficiency and quality. When seeking to improve existing procedures, the 5 Whys Technique serves as a valuable tool. By systematically analyzing the factors contributing to inefficiencies or bottlenecks, teams can gain insights into how processes can be optimized at their core. This method enables organizations to make informed decisions about process improvements based on a deep understanding of the underlying issues.

In both cases, the 5 Whys Analysis offers a structured yet flexible approach to delve into complex problems, making it an indispensable tool for driving meaningful change and progress within organizations.

When it comes to conducting a 5 Whys analysis, utilizing a structured template can greatly facilitate the process and ensure a comprehensive investigation into the root cause identification. Using RCA software such as EasyRCA can benefit the team by streamlining your 5-why process. Here’s how organizations can benefit from using a template:

Screenshot of 5 Why Root Cause Analysis Software - EasyRCA 5 Why Template

Benefits of Using a Template

Streamlined Process: A well-designed 5 Whys template provides a clear framework for conducting the analysis, guiding teams through the iterative questioning process. This streamlines the investigation, making it easier to navigate and ensuring that no crucial aspects are overlooked.
Thorough Investigation: By following a predefined template, teams are prompted to explore various facets of the problem systematically. This ensures that all relevant factors are considered, leading to a more thorough and insightful investigation into the underlying causes.
Consistent Approach: Templates offer a standardized approach to conducting 5 Whys analyses within an organization. This consistency promotes uniformity in problem-solving methods across different teams or departments, enhancing overall efficiency and effectiveness.

Customizing the Template

Organizations have the flexibility to customize 5 Whys templates according to their specific needs and industry requirements. This adaptability allows for tailoring the template to address unique challenges and incorporate industry-specific considerations. Customization may include:

Adding Industry-Specific Prompts: Tailoring the template by incorporating prompts or questions relevant to particular industries or types of issues being analyzed.
Incorporating Visual Aids: Enhancing the template with visual aids such as flow charts or diagrams can help teams better understand and communicate complex causal relationships.
Iterative Refinement: Regularly reviewing and refining the template based on feedback and evolving organizational needs ensures that it remains aligned with current processes and challenges.

Customizing the template empowers organizations to harness the full potential of the 5 Whys Technique in addressing diverse problems while aligning with their unique operational contexts.

Encouraging Open Communication

In mastering the 5 Whys Technique as a problem-solving method, creating an environment that fosters open communication is paramount. When team members feel comfortable expressing their perspectives and insights, it leads to a more comprehensive exploration of the underlying causes of a problem. Encouraging open communication allows for diverse viewpoints to be considered, providing a holistic understanding of the issue at hand.

By promoting an atmosphere where individuals are empowered to voice their observations and concerns, the 5 Whys analysis can benefit from a rich tapestry of ideas and experiences. This inclusive approach not only enhances the depth of the analysis but also cultivates a sense of ownership and collective responsibility for addressing root causes within the team or organization.

Continuous Improvement Mindset

A key aspect of mastering the 5 Whys Technique is embracing a continuous improvement mindset. Rather than viewing problems as isolated incidents, this approach encourages teams to see them as opportunities for growth and development. By instilling a culture of continuous improvement, organizations can leverage the insights gained from 5 Whys analyzes to drive positive change across various aspects of their operations.

Fostering a mindset focused on continuous improvement entails actively seeking feedback, evaluating processes, and implementing iterative enhancements based on the findings. It involves an ongoing commitment to learning from past experiences and leveraging that knowledge to proactively address potential issues before they escalate. Embracing this mindset ensures that the 5 Whys Technique becomes ingrained in the organizational ethos, leading to sustained progress and resilience in problem-solving efforts.

As we wrap up our exploration of the 5 Whys Technique, let’s address some common questions that may arise regarding this powerful problem-solving method.

What is the primary goal of the 5 Whys Technique?

The primary goal of the 5 Whys Technique is to uncover the root cause of a problem by iteratively asking “why” at least five times. This approach aims to move beyond surface-level symptoms and address the underlying issues that lead to recurring problems.

Is the 5 Whys Technique limited to specific industries or sectors?

No, the 5 Whys Technique is versatile and can be applied across various industries and sectors. Whether it’s manufacturing, healthcare, service, or technology, this method offers a structured yet flexible approach to identifying root causes and driving continuous improvement.

How does the 5 Whys Technique contribute to continuous improvement?

By delving into the fundamental reasons behind problems, the 5 Whys Technique provides organizations with valuable insights for driving continuous improvement. It not only helps in resolving immediate issues but also fosters a culture of ongoing enhancement and development within an organization.

Can the 5 Whys Technique be used for complex problems with multiple contributing factors?

Yes, while initially designed as a simple and straightforward method, the 5 Whys Technique can certainly be applied to complex problems with multiple interconnected factors. By systematically probing deeper into each layer of causality, this technique enables a comprehensive understanding of intricate issues.

I hope you found this guide to 5 whys technique insightful and actionable! Stay tuned for more thought-provoking articles as we continue to share our knowledge. Success is rooted in a thorough understanding and consistent application, and we hope this article was a step in unlocking the full potential of Root Cause Analysis for your organization.

Reliability runs initiatives such as an online learning center focused on the proprietary PROACT® RCA methodology and EasyRCA.com software. For additional resources, visit Reliability Resources .

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‘The Problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution.

The ‘5 whys’ technique is one of the most widely taught approaches to root-cause analysis (RCA) in healthcare. Its use is promoted by the WHO, 1 the English National Health Service, 2 the Institute for Healthcare Improvement, 3 the Joint Commission 4 and many other organisations in the field of healthcare quality and safety. Like most such tools, though, its popularity is not the result of any evidence that it is effective. 5–8 Instead, it probably owes its place in the curriculum and practice of RCA to a combination of pedigree, simplicity and pedagogy.

This quote also makes the case for the technique's simplicity. Asking ‘why’ five times allows users to arrive at a single root cause that might not have been obvious at the outset. It may also inspire a single solution to address that root cause (though it is not clear that the ‘1H’ side of the equation has been adopted as widely).

‘5 whys’ as a teaching tool

The pedagogical argument for ‘5 whys’ is that it creates an ‘aha moment’ by revealing the hidden influence of a distant cause, which illustrates the importance of digging deeper into a causal pathway. This quick and easy learning experience can be a powerful lesson in systems safety and QI.

Possibly the most famous ‘5 whys’ case study to be used in this way focuses on efforts to preserve the Washington Monument. 12 , 13 Details vary slightly depending on the source, but it usually looks something like this:

Problem : The Washington Monument is deteriorating

Why? Harsh chemicals are being used to clean the monument

Why? The monument is covered in pigeon droppings

Why? Pigeons are attracted by the large number of spiders at the monument

Why? Spiders are attracted by the large number of midges at the monument

Why? Midges are attracted by the fact that the monument is first to be lit at night.

Solution: Turn on the lights one hour later.

This is a great teaching example because the ‘root cause’ is so unintuitive. Who would think, before exploring the issue in depth, that lighting choices could endanger a marble monument? But, as is so often the case, reality is messier than this simple illustration.

Joel Gross 12 investigated the foundation of this example and discovered that many of the details are incorrect. And, crucially, the broader story it tells is incomplete.

In terms of the story's details, the monument is question was actually the Lincoln Memorial, and it was not being damaged by the use of harsh chemicals. The real culprit was simply water. Pigeons were not an issue at all, and while there were ‘tiny spiders’ (ref. 14 , p. 8) at the memorial, they were not a major problem. Instead, most of the cleaning was necessary because swarms of midges were dazzled by the lights and flew at high speed into the walls of the memorial, leaving it splattered with bits of the insects and their eggs. 12 , 14

But that only speaks to the details that were described. The analysis is also incomplete in a number of more important ways. For instance, it only addresses one potential source of deterioration: cleaning water.

The first ‘why’ could just as easily have tackled other causes, such as rain or acid rain (a significant concern at the time), rising damp, erosion from windborne particles or damage from freeze-thaw cycles. 15 Or, if the goal had been to prevent harm to future monuments, the first ‘why’ could have focused on the use of marble as a building material, the choice of building site, etc.

However, the most important problem with this example is that, while the solution was ‘effective’ in one sense, it still failed: Messersmith [the consultant entomologist who worked on this project] thought that because the insects swarmed only at sunset, a one-hour delay in turning on the monument lights would go far in solving the problem. The technique worked, reducing the number of midges in the monuments by about 85 percent. ‘But tourists who had driven hundreds of miles to have their photographs taken at the monuments were not happy,’ he said. ‘They complained every day, and the lights went back on.’ 16

The logic of the solution was sound, as far as it went. But it was predicated on an incomplete understanding of the broader system, its stakeholders and the purpose of the monument itself. If anything, this window on the complexity of real-world problem solving adds to the value of this teaching example. If the first ‘aha moment’ is followed by this second one, trainees will not only learn that distal causes can have unexpected outcomes, but also that systems thinking requires both depth and breadth of analysis.

The problem with ‘5 whys’ in RCA

‘5 whys’ has been the subject of a number of caveats and critiques. For instance, Minoura, one of Ohno's successors at Toyota, highlights the potential for users to rely on off-the-cuff deduction, rather than situated observation when developing answers, as well as difficulty in prioritising causes, if multiple ‘5 whys’ are used. 17 Mark Graban, a thought leader in the Lean community, points out that ‘5 whys’ is just one component of what should be a far more comprehensive problem-solving process. 18 And Serrat clarifies that users should not feel constrained by the arbitrary number in the tool's title: more, or fewer, than five ‘whys’ may be required. 19

But the real problem with ‘5 whys’ is not how it is used in RCA, but rather that it so grossly oversimplifies the process of problem exploration that it should not be used at all. It forces users down a single analytical pathway for any given problem, 13 insists on a single root cause as the target for solutions 9 , 13 , 20 and assumes that the most distal link on the causal pathway (the fifth ‘why’) is inherently the most effective and efficient place to intervene.

A single causal pathway

A credible ‘5 whys’ approach to a wrong patient medication error might look like this (adapted from Battles et al ): 21

Incident : Wrong patient medication error

Why? Wristband not checked

Why? Wristband missing

Why? Wristband printer on the unit was broken

Why? Label jam

Why? Poor product design

But another team could easily come up with five wholly different and equally valid ‘whys’. And any single string of ‘5 whys’ can provide only a blinkered view of the complex causal pathway that led to the incident. This is illustrated by figure 1 , a causal tree diagram (or, more accurately, a ‘causal and contributing factors tree diagram’) depicting the underlying issues that gave rise to the adverse event.

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A causal event tree (adapted from ref. 21 ). ID, identification; IT, information technology.

It is clear from the tree diagram that the causal pathway related to the wristband printer is neither the only relevant cause of the incident nor indisputably the most important. A serious effort to solve the myriad problems that gave rise to this incident would have to tackle a number of other causal pathways as well.

These might include pathways related to a maladaptive workplace culture, 22–25 clinical and information technology (IT) staffing, orientation of agency staff and the absence of a forcing function 26 to ensure that patients are properly identified before medication is administered. It could also include a focus on improved infection control and better preparedness for infectious disease outbreaks. Solutions based on the ‘5 whys’ in the example above would leave all of these issues unaddressed.

There is also no objective or reliable means of mapping out the causal pathway, which is a critical failing when only one pathway will be examined. Consider the variant below, which follows essentially the same causal reasoning as the first example:

Why? Healthcare system purchased an unreliable printer

Why? Poor process for evaluating and purchasing ‘non-clinical’ equipment

Why? Equipment deemed ‘non-clinical’ is not seen as safety-critical

This version skips the step of asking why the wristband was not checked and moves directly to asking why it was not there. It also sticks to the high-level issue of the printer being broken, without delving into the details of the label jam. ‘Skipping’ these questions allows the analysis to go deeper because it leaves more ‘whys’ available. This example also maintains a focus on issues within the organisation, rather than the design of the printer. This would lead to very different solutions.

But because this approach skips past the question of why the wristband was not checked, it closes the door to questions about other reasons why it was not checked. In figure 1 , this would include the lack of a forcing function. But in another scenario, it might include a desire to avoid waking the patient; 27 an unreadable wristband (eg, smudged, crinkled or occluded); 28 the lack of a label on the medication; 29 confusion caused by multiple wristbands; 30 lack of trust in the wristband data due to frequent errors 31 or any of a number of other causes. 28–31

Users could also go down an entirely different causal pathway. An equally reasonable ‘5 whys’ for this incident could look like this:

Why? Patients with similar names in the same room

Why? Not feasible to try ‘juggling beds’

Why? Not enough nurses to deal with the influx of patients

Why? Nurses affected by an outbreak of norovirus

Why? Poor adherence to time-consuming infection control interventions

Why? A culture of ‘just get the job done’

There are many ‘correct’ ways a team might use ‘5 whys’ to assess even this one incident. And it is unlikely that any two teams would independently arrive at exactly the same results. This subjectivity is critically important because ‘5 whys’ focuses on only one root cause at the end of one causal pathway.

More sophisticated practice in the use of ‘5 whys’ might produce two causal pathways, focusing on the main service failures uncovered, rather than the event itself (ie, a set of ‘5 whys’ for ‘wristband not checked’ and another for ‘verbal identification failure’). But this is not how use of the tool has generally been taught in the healthcare industry. 1 , 3 , 32 And even this unusually thorough approach would identify only 2 of the 30 causal pathways shown in the tree diagram.

A single root cause

Forcing users down a single causal pathway should be disqualifying by itself. But ‘5 whys’ narrows the scope for improvement even further by insisting that risk control efforts must focus on a single root cause for each causal pathway. In the first healthcare example above, for instance, the root cause would be ‘poor product design’, and this would serve as the sole target for improvement efforts.

But accidents are seldom the result of a single root cause. 33 So focusing exclusively on one (or even a few) arbitrarily determined ‘root causes’ is not a reliable method for driving improvement—especially in a system as complex as healthcare. As Wieman and Wieman wrote: “Unfortunately … restricting the number of variables [considered] in a complex system only results in an increased potential for errors of omission” (ref. 34 , p. 117).

How much might be omitted when using ‘5 whys’? The tree diagram for our example uncovers more than 75 whys (causes and contributing factors), each of which is a potential target for action to reduce the risk of a recurrence. The ‘5 whys’ approach would identify only one (or possibly two) root cause as target for action. At best, this represents <3% of the opportunities for improvement identified using the tree diagram.

Targeting only the most distal cause

Not only are users of ‘5 whys’ limited to one root cause per causal pathway, but they are also limited to selecting only the most distal cause (conventionally, the fifth ‘why’). There is, however, no logical reason to assume that this is always the most effective or most efficient target for intervention.

Actually, if it were possible to magically place a 100% effective risk control at any one point on the tree diagram, it would be best used on a proximate cause. For instance, making it impossible to administer medication without checking the wristband would render all the more distal causes moot for the purpose of preventing a recurrence.

And, while 100% effective risk controls are seldom available, an action plan that includes a proven 26 (if certainly imperfect) 29 intervention like a well-designed bar-code reader with a forcing function for patient identification (ID) is more likely to prevent another serious ‘wrong patient’ medication error than switching to a well-designed printer.

This is not to suggest that more distal causes are not appropriate targets for improvement efforts. In the example presented in figure 1 , for instance, there is clearly a profound need to change the culture from one that is task-oriented and sometimes hostile to one that is outcomes-oriented and psychologically safe. The pervasive impact of such a culture change would be far more important than merely reducing the risk that this particular incident might recur; it would influence almost every quality and safety issue in the organisation.

And, in contrast to that powerful-but-difficult lever for shifting outcomes, sometimes more distal causes represent ‘low-hanging fruit’ that can be addressed while a more proximate solution is in the works. In figure 1 , educating patients about why clinicians will be constantly asking them to identify themselves would be far from foolproof. But it would be fast, cheap and easy. And it might reduce an important barrier to best practice in verbal identification.

Appropriate targets for intervention may occur anywhere along the causal continuum and on any causal pathway. And efforts to improve safety and quality will often require more than one intervention targeting more than one underlying hazard. It is useful to identify all the key hazards that gave rise to an incident and ensure that each of these is either addressed or intentionally accepted. 35 (See, for instance, the Options Evaluation Matrix.) 36 But the use of ‘5 whys’ makes this impossible.

Considering the virtues of ‘5 whys’

What, then, of the virtues of ‘5 whys?’ Are the issues above redeemed by the tool's simplicity and pedigree?

Simplicity is a complicated virtue when it comes to the frameworks, tools and techniques of QI. For instance, the conceptual simplicity of the Plan-Do-Study-Act (PDSA) framework is one of its main selling points, but it may also lead organisations to underestimate the messy work involved in applying PDSA to real-world problems. 37

But, as this paper has shown, the ‘5 whys’ approach has clearly overshot the mark: it is not simple, but simplistic . It is, as Leveson describes, “… perhaps the most simplistic [accident analysis technique] and … leads to the least amount of learning from events”. 13

Charles Vincent famously called for RCA to serve as “a window on the system”. 38 If that is the goal, then ‘5 whys’ is doomed to fail. It purposely discards the vast majority of what might be learned about the system being interrogated.

The reality of most healthcare processes and systems is that we face classic design problems: problems that are highly contextualised and often “ill-defined, ill-structured, or ‘wicked’” 39 (ref. 40 , p. 224). A ‘5 whys’ analysis ignores this. Most of the causal pathways that led to an event are amputated from the start, and consideration of those that remain is limited to a single root cause.

This creates a toy problem i in which it is assumed that simple optimisation of one, or at most a handful of variables will lead to improvement, without any need to consider the rest of the system. This flies in the face of everything we know about solving problems in complex adaptive systems like healthcare. 41

The positive reputation enjoyed by TPS/Lean provides an aura of credibility for ‘5 whys’. But how applicable is this to the question at hand? The reputation of TPS/Lean was built in a very different context. And the use of ‘5 whys’ as an RCA tool is by no means the same thing as the use of the full TPS/Lean methodology.

Healthcare organisations are not automobile factories. And while there is much to be learned from the automotive industry and other high-reliability organisations (HROs), healthcare delivery will never be truly comparable to automobile manufacturing. Despite efforts in the healthcare industry to adopt the tenets of HROs, 42 , 43 current practice provides recommended care only about 70% of the time. 44 And the percentage of hospital patients who experience an adverse event may be as high as 25–33%. 45–50

HROs commonly aim for a reliability rate of ‘six sigma’ (three errors per million opportunities). By these measures, healthcare is struggling to move beyond two sigma (308 500 errors per million opportunities, or a 30.85% error rate). 51

Reliability in the healthcare industry can improve, and indeed it has (cf. ref. 52). But healthcare is far more complex 34 , 53 than automobile manufacturing, and takes place amid processes and systems that are woefully underdesigned in comparison to a modern factory. Further, the safety and quality workforce in healthcare is only beginning to move towards professionalisation 54 , 55 and often lacks formal training in engineering, human factors, ergonomics or similar domains.

As a result, approaches developed for solving problems in the automotive manufacturing context may not be as effective in the healthcare arena. And, indeed, the evidence base for the use of Lean/TPS in healthcare is weak 56–58 and increasingly negative. 59 , 60

It is also important to differentiate between the use of ‘5 whys’ as a QI method and the use of Lean/TPS as a QI methodology. Though the two are sometimes conflated in both the literature 59 and practice, 61 they are by no means equivalent. And the use of ‘5 whys’ in healthcare RCA is not typically part of a full-scale Lean management approach.

If the use of ‘5 whys’ does not imply the adoption of Lean, and if the evidence to date does not support the effectiveness of Lean in healthcare in any case, there is little reason to be swayed by the pedigree argument.

Using ‘5 whys’ undermines an already weak RCA process

A recent article by Peerally et al 33 describes a number of important weaknesses in healthcare RCA practice. Some of these have been explored above (eg, focusing on a single root cause or a small handful of them; and poor quality investigations), but it also raises a number of other issues, such as misuse of the RCA process to pursue (or avoid) other agendas; failure to support feedback loops and double-loop learning; a focus on individual and isolated incidents; a confused approach to blame; the ‘problem of many hands’ (see also ref. 63 ) and the shortfalls of a retrospective approach.

The authors also note that RCA often results in poorly designed and/or poorly implemented risk controls. 33 While the goal of learning from incidents is to reduce risk and prevent future harm, the actual tools and techniques of current practice focus exclusively on diagnosing problems; they provide no direct support for prescribing and managing treatments for the organisational pathologies they uncover. 64 , 65

Some organisations have adopted the PDSA approach to continuous improvement of their risk control action plans. 37 , 66 But this is a high-level framework, akin to the scientific method. And like the scientific method, it must be implemented through an appropriate set of tools and techniques to produce reliable results. 37 Although a handful of such tools have been introduced in recent years, 35 , 36 , 67–72 they have not yet been adopted as the current standard of practice.

Perhaps as a result, there is little evidence to suggest that current practice in RCA improves outcomes. 65

These challenges do not mean that RCA is never worthwhile; it certainly can be a source of important learning 73 and improvement. 74 But it does mean that we cannot afford to compound these problems through the use of an RCA tool that is so deeply and fundamentally flawed. Other more systems-focused techniques, such as fishbone 75 or lovebug diagrams, 72 causal tree diagrams, 21 Causal Analysis based on Systems Theory (CAST) 76 or even prospective risk assessment approaches, 77–81 should be considered instead.

When used carefully, ‘5 whys’ may play a powerful role in the classroom. It can illustrate both the need for depth (as a positive example) and the need for breadth (as a negative example) when analysing complex problems.

As a tool for conducting RCAs, however, especially in the area of patient safety, the use of ‘5 whys’ should be abandoned. As the (apocryphal) quote goes: “For every complex problem, there is an answer that is clear, simple and wrong”. 82 When it comes to accident investigation, ‘5 whys’ is that answer.

↵ World Health Organisation . The WHO patient safety curriculum guide: multi-professional edition . Geneva , 2011 .
↵ NHS Improving Quality . Improvement tools. http://www.nhsiq.nhs.uk/improvement-programmes/patient-safety/improvement-resources/improvement-tools.aspx (accessed 28 Jan 2016 ).
↵ Institute for Healthcare Improvement . Ask ‘why’ five times to get to the root cause. Improv. stories. http://www.ihi.org/resources/Pages/ImprovementStories/AskWhyFiveTimestoGettotheRootCause.aspx (accessed 28 Jan 2016 ).
↵ The Joint Commission . Sentinel event policy and procedures . 2016 . http://www.jointcommission.org/sentinel_event_policy_and_procedures/ (accessed 28 Jan 2016 ).
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Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

↵ i A toy problem is: “A deliberately oversimplified case of a challenging problem used to investigate, prototype, or test algorithms for a real problem. Sometimes used pejoratively”. 62

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The Simple Yet Powerful 5 Whys Method for Effective Problem-Solving

Updated: May 16, 2023 by Lori Kinney

As a child, you were always asking your parents “Why this?” “Why that?” “Why can’t I do this?” “Why can’t I do that?” Little did you know that you were preparing yourself to be a problem-solver looking for root causes when you would grow up.

This article will discuss what is the 5 Why method of looking for a problem’s root cause, how to correctly ask the questions, and what benefits and best practices there might be to help you do a better job of improving your processes.

Overview: What are the 5 Whys?

The 5 Whys technique was developed in the 1930s by Sakichi Toyoda, the Japanese industrialist, inventor, and founder of Toyota Industries. The 5 Whys technique is an iterative, team-driven process that interrogates the problem by asking Why(?) a number of times, usually 5, thus driving the search to uncover the root cause of a problem.

Rather than using the phrase “solutions” once the root cause is found, the 5 Whys uses the term “countermeasures.” A countermeasure is action-oriented and seeks to prevent the problem from happening again, whereas a solution may just seek to deal with the symptoms.

Here is the 5 Why technique in a nutshell:

First, you must have a defined problem. Put together a team to address the problem. Then:

List: Using a white board, flip chart, butcher paper, or other visual display, list five potential reasons for your problem.
Evaluate: Using data, subject matter experts, or experience, evaluate each of the five potential reasons.
Select: Select the one reason that seems to be the most likely potential cause.
List again: Now list five potential reasons for the potential cause that you selected.
Evaluate again: Evaluate those five new potential reasons.
Select again: Again, select the one reason that seems to have the most potential as a root cause.

Repeat the process of list, evaluate, and select as many times as needed until you feel that the root cause has been uncovered. The

Unfortunately, many organizations don’t do the 5 Whys the correct way. Often, they:

Look at the problem
Offer one potential cause
Ask “Why?” for that one cause
And continue one at a time

In the end, you will have only explored five potential causes. Doing it with the list, evaluate, and select approach, you will have assessed 25 potential causes by listing five for each iteration.

3 benefits of the 5 Whys

This technique has been around since the 1930s. It has been shown to work and can be successfully applied to many situations.

1. It is a simple yet powerful tool

With just the use of a flip chart and a few markers, a group of people can usually get to the root cause of a problem relatively quickly.

2. A sking “why” 5 times focuses the team on getting to the root cause

Using this approach in a disciplined fashion will get you to focus on the causes and prevent you from jumping to conclusions as to the solution.

3. Helps engage the people who deal with the problem

Getting input from the people who deal with the problem and making them part of the solution can result in better buy-in and engagement.

Why are the 5 Whys important to understand?

While the 5 Why technique is simple, you must understand the proper mechanics of the method so that you get the best results possible.

It encourages collaborative problem-solving

Getting the team to collaboratively work together is not only important for the 5 Why problem solving session but for any future activities that would improve the process.

You want to focus on improvement, not blame

Do not allow such causes as “ human error,” “employee attitude,” “communication,” and other generic and ill-defined reasons to be used as the root cause.

Understand the importance of having support from leadership

Hopefully, in the end, the team will come up with a number of countermeasures that will remove the root cause(s) of a problem. It will usually fall upon leadership to provide the resources to make the change. Avoid future frustration by having management on board with this technique from the beginning.

An example of the 5 Whys in use

An example is in order.

You are on your way home from work, and your car stops:

Why did your car stop? Because it ran out of gas.
Why did it run out of gas? Because I didn’t buy any gas on my way to work.
Why didn’t you buy any gas this morning? Because I didn’t have any money.
Why didn’t you have any money? Because I lost it all last night in a poker game.

This example should illustrate the importance of digging down beneath the most proximate cause of the problem. Failure to determine the root cause assures that you will be treating the symptoms of the problem instead of its cause, in which case, the disease will return — that is, you will continue to have the same problems over and over again.

Also note that the actual numbers of whys is not important as long as you get to the root cause. One might also ask, “Why did you lose all your money in the poker game last night?”

Here’s another example. The Washington Monument was disintegrating:

Why? Use of harsh chemicals
Why? To clean pigeon poop
Why so many pigeons? They eat spiders and there are a lot of spiders at monument
Why so many spiders? They eat gnats and lots of gnats at monument
Why so many gnats? They are attracted to the light at dusk.

Countermeasure: Turn on the lights at a later time.

3 best practices when thinking about the 5 Whys

Doing the 5 Whys is simple, but not easy. Keep the team on task and take advantage of the team members’ knowledge, experience, and enthusiasm.

1. Don’t try to do this alone; use a group of people involved in the process

Five heads are better than one. Select a diverse group of team members to get the widest perspective.

2. Focus on counter measures rather than solutions

The solution to a headache is to take two aspirin. The countermeasure to a headache is to find out what is causing it and remove it.

3. Be open and respectful of everyone’s input and participation

Everyone’s idea has value. You never know who might hold the hidden gem. Listen and be respectful so people will feel comfortable offering their ideas — you’ll also have better buy-in once you find the root cause.

Frequently Asked Questions (FAQ) about the 5 Whys

Can i ask more than 5 whys .

Yes. You can ask more than five or less than five. The key is, how many questions does it take to get to what appears to be the root cause.

Can I use the computer to do the 5 Why exercise?

It’s recommended that you use something more tactile like flip charts. This way, you can tear them off and hang them on the wall for everyone to see. The more visual you make the work, the better.

Should my manager run the 5 Why session or someone else?

Since the manager often has a stake in the outcome of the process, it might be best to use a neutral facilitator who can help keep the team on task, ask the right questions, and not get defensive when the potential causes are mentioned.

The 5 Whys wrapped up

The 5 Whys is an iterative, team-based approach to asking questions about the potential causes of a problem. Once the problem is defined, the potential causes should be listed, evaluated, and selected, and then repeated as many times as necessary to get to the root cause.

Once the root cause(s) is identified, the team should recommend specific, action-oriented countermeasures to mitigate or eliminate the root cause of the problem. Remember, don’t just address the symptoms; you must find the underlying cause, otherwise the problem will resurface sometime in the future.

About the Author

Lori Kinney

5 Whys Folklore: The Truth Behind a Monumental Mystery

Unravel the enigmatic layers of folklore through the lens of the '5 Whys' methodology. Delve into the monumental mysteries that have captivated generations, and discover the truth that lies beneath the tales we've all grown to love.

The Lincoln Memorial Lighting and Midge Study

Although the work predated the Google search by nearly a decade, and despite never warranting an official publication, there are more than 140,000 pages on the internet which reference the study.

Why should we care about some little-known, unpublished report from a study on insect behavior performed almost 25 years ago?
Sitting in a file folder in the desk drawer of Don Messersmith resides a report on perhaps the single, most famous problem ever solved

The Moral of the Story

Without knowing the whole story, it’s difficult to say exactly what the most important lesson is.

Perhaps it’s the value that a thorough understanding of cause and effect has on the efficiency and effectiveness of solutions.
Or, perhaps, the importance of hope.
Because if recent images of the Lincoln Memorial and the Jefferson Memorial at sunset are any indication, than there might just be hope for my government yet.

The Classic 5 Whys Example: A Monumental Mystery

The 5-whys is a method of root cause analysis in which the learner repeatedly asks, “why?” in order to drill down from higher-level symptoms to the underlying root cause(s) of a problem.

Deep understanding of the root causes of our problems yields simpler and more effective solutions.

Debunking the 5-Whys Example

Whose monument is it, anyway?

Some versions specify the Washington Monument, but this is relevant to both the Jefferson and Lincoln memorials
Cleaning chemicals are not the sole cause of the deterioration
The large amount of bird droppings from starlings and sparrows did contribute to the need for daily scrubbing of both monuments
Large volume of water applied during the cleaning process poses the greatest threat to the marble and limestone buildings
Midges (not gnats) swarmed to the river-side monuments because the lights replicated their preferred mating conditions
When it came to the lighting of the monument as a solution to the problem of deterioration, there are really two separate myths at play
First, the true impact of the story comes from the belief that a simple story can effectively prevent a recurrence of problems of which there are multiple solutions to
Second, the whole story becomes very analytical and detailed
It must be noted that both versions of this particular problem take place over a whole lot more years than just five

Strategies to Excel in Uncertain Times

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COMMENTS

5 Whys Example: The Truth Behind a Monumental Mystery
The 5 whys example about the crumbling monument is known to most in the Lean, Six Sigma & improvement worlds, but very few know the true story. ... Lincoln Memorial Lighting and Midge Study. Unpublished report prepared for the National Park Service. ... The facts are that the case study is relevant to both the Jefferson and the Lincoln ...
PDF THE PROBLEM WITH The problem with 5 whys
Possibly the most famous '5 whys' case study to be used in this way focuses on efforts to preserve the Washington Monument.12 13 Details vary slightly depending on the source, but it usually ... Lincoln Memorial, and it was not being damaged by the use of harsh chemicals. The real culprit was simply water.
(PDF) The problem with '5 whys'
The '5 whys' technique is one of the most widely taught approaches to root-cause analysis (RCA) in healthcare. ... 1_monuments-park-service-lincoln-memorial. ... The case study exemplifies the ...
Saved Post: 5-Whys Folklore: The Truth Behind a Monumental Mystery
Lincoln Memorial Lighting and Midge Study. Unpublished report prepared for the National Park Service. CX-2000-1-0014. ... the work has become the quintessential case study on the application of the "5-whys". A Monumental Mystery. The 5-whys is a method of root cause analysis in which the learner repeatedly asks, "why?" in order to drill ...
Root Cause Analysis
The most famous example is of the Lincoln Memorial in Washington. The summary of this Five Whys example is reproduced below from an article by Joel A Gross: Problem: The Lincoln Memorial in Washington D.C. is deteriorating. ... This certainly applies in my case. In fact, the company where I learned to use "5-Why Cause investigation" had a ...
The 5 Why Problem-Solving Technique
Use the 5 Why examples to improve your skills and conduct root causes analysis. Find 5 Why examples for your 5 Why Training needs. ... Lincoln Memorial Lighting and Midge Study. Unpublished report prepared for the National Park Service. CX-2000-1-0014. N.p. ... Small Steps, Big Gains: The Case for Incremental Improvement . Maximising Efficiency ...
The Power of 5 Why's at the Lincoln Memorial
Here's a famous example involving the Lincoln Memorial. Root cause analysis is an incredibly powerful tool. Here's a famous example involving the Lincoln Memorial.
The Five Whys Approach To Finding Root Causes
The five whys has an important role to play in problem solving. It is used within the A3 Thinking approach to problem solving. When looking for effective long term solutions to problems, it's essential to understand the actual root causes as to why something is happening. Five Whys analysis is a process to identify these root cause.
The Lincoln Memorial and the 'five whys'
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Root Cause Analysis Blog
To recap, 5-Whys is a simple, stripped-down method of root cause analysis (RCA) in which the investigator repeatedly asks, "why?" in order to drill down from higher-level symptoms to the underlying root cause (s) of a problem. The story covers the woes of the Jefferson Memorial in Washington DC and dates back to the late 1980s when the ...
PDF Problem: The Washington Monument was falling apart. The 5 Whys
Why? Because spiders feasted on all the gnats there. Why? Because gnats were attracted to the lights at dusk. Why? Because the monument was 1st to turn its lights on. Solution: Turn the lights on 30 minutes later! Problem solved . . . or was it? Discover the true story behind this monumental mystery only at: A real life case study in root cause ...
PDF The 5 Whys
Asking why more or less than five times is ok, as long as you identify the root cause. If you can't answer "why" any more, you likely found the root cause. There can be more than one cause to a problem. EXAMPLE . Problem Statement: The Lincoln m emorial is deteriorating. Why. is the memorial deteriorating? Because
Root Cause Analysis with 5 Whys Technique (With Examples)
Step 1: Identify the Problem. Before diving into a 5 Whys analysis, it's crucial to clearly identify the problem or issue at hand. This step sets the stage for the entire process and ensures that the focus remains on addressing the right concern. Take the time to gather relevant data, observe patterns, and consult with team members or ...
The problem with '5 whys'
Possibly the most famous '5 whys' case study to be used in this way focuses on efforts to preserve the Washington Monument.12, 13 Details vary slightly depending on the source, ... the monument is question was actually the Lincoln Memorial, and it was not being damaged by the use of harsh chemicals. The real culprit was simply water.
The Simple Yet Powerful 5 Whys Method for Effective Problem-Solving
3 benefits of the 5 Whys. This technique has been around since the 1930s. It has been shown to work and can be successfully applied to many situations. 1. It is a simple yet powerful tool. With just the use of a flip chart and a few markers, a group of people can usually get to the root cause of a problem relatively quickly. 2. Asking "why ...
5 Whys Folklore: The Truth Behind a Monumental Mystery
Unravel the enigmatic layers of folklore through the lens of the '5 Whys' methodology. Delve into the monumental mysteries that have captivated generations, and discover the truth that lies beneath the tales we've all grown to love. The Lincoln Memorial Lighting and Midge Study Although the work predated the Google
PDF Root Cause Analysis: The 5 Why's
The "5 Why's" refer to the practice of asking, five times, why the situation has occurred in order to get to the root cause(s) of the problem. It illustrates the importance of digging down beneath the most obvious cause of the problem. Failure to determine the root cause assures that you will be treating the symptoms of the problem instead ...
The Jefferson Memorial and the 5 Whys
Ever wonder if we really got to the root of a problem? This is a video about a near miss and a simple solution!
Five Whys Jefferson Memorial Example
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Lincoln Memorial Case Study Of 5 Whys
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Five Whys (Root Cause Analysis) Jefferson Memorial Example
Five Whys analysis is a process to identify these root cause. For our example, the Jefferson Memorial, in Washington DC was eroding very quickly, meaning it...
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‘5 whys’ as a teaching tool

The problem with ‘5 whys’ in RCA

A single causal pathway

A single root cause

Targeting only the most distal cause

Considering the virtues of ‘5 whys’

Using ‘5 whys’ undermines an already weak RCA process

Read the full text or download the PDF:

The Simple Yet Powerful 5 Whys Method for Effective Problem-Solving

Overview: What are the 5 Whys?

3 benefits of the 5 Whys

1. It is a simple yet powerful tool

2. A sking “why” 5 times focuses the team on getting to the root cause

3. Helps engage the people who deal with the problem

Why are the 5 Whys important to understand?

It encourages collaborative problem-solving

You want to focus on improvement, not blame

Understand the importance of having support from leadership

An example of the 5 Whys in use

3 best practices when thinking about the 5 Whys

1. Don’t try to do this alone; use a group of people involved in the process

2. Focus on counter measures rather than solutions

3. Be open and respectful of everyone’s input and participation

Frequently Asked Questions (FAQ) about the 5 Whys

Can I use the computer to do the 5 Why exercise?

Should my manager run the 5 Why session or someone else?

The 5 Whys wrapped up

About the Author

Lori Kinney

5 Whys Folklore: The Truth Behind a Monumental Mystery

The Lincoln Memorial Lighting and Midge Study

The Moral of the Story

The Classic 5 Whys Example: A Monumental Mystery

Debunking the 5-Whys Example

Strategies to Excel in Uncertain Times