5 Why's Help Needed

TacitBlue

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Start with your problem description (not the symptom) and ask the first why. The problem description should contain a specific Object with a specific Defect.

Miner, to that end, should my problems statement state: ENG0002 Form G, Rev. D, does not show a BPR review number as required by DOC0013?
 

Miner

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I would agree with that. Your Object is the stated form and the Defect is a missing BPR review number.
 

Miner

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Problem: The ENG0002 Form, Rev. D does not include a *BPR review number and is designated as N/A; additional investigation revealed that no proof of a BPR review was conducted is on file.

WHY1: Without completing the BPR review process, the document was released to All Business Processes (our main procedure library).

This where you need to be careful because you have conflated two issues into a single why.
  • Issue 1: The BPR review process was not completed (Occurrence cause path)
  • Issue 2: The document was released without the review process (Escape cause path)
When you conflate the different branches of a 5 why, you can end up with a tangled mess with a root cause that doesn't make sense.
 

TacitBlue

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This where you need to be careful because you have conflated two issues into a single why.
  • Issue 1: The BPR review process was not completed (Occurrence cause path)
  • Issue 2: The document was released without the review process (Escape cause path)
When you conflate the different branches of a 5 why, you can end up with a tangled mess with a root cause that doesn't make sense.

In that case, should by first "why" be that, "the BPR review and approval process was not completed" or that "a BPR form was never submitted for the document"?
 

Miner

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That is difficult for someone outside of the process to say with certainty, but I would lean towards "a BPR form was never submitted for the document." The next why might be that "the BPR review and approval process was not completed" (therefore a BPR form was never submitted for the document). However, I have no way of knowing whether a BPR review was indeed held, but the form never submitted for an entirely different reason.
 

TacitBlue

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That is difficult for someone outside of the process to say with certainty, but I would lean towards "a BPR form was never submitted for the document." The next why might be that "the BPR review and approval process was not completed" (therefore a BPR form was never submitted for the document). However, I have no way of knowing whether a BPR review was indeed held, but the form never submitted for an entirely different reason.

Hi Miner, to look at this objectively, I don't know 100% certain that the BPR process was never conducted, as this document dates back to 2017 or 2018; however, if the process was indeed followed, a BPR number would have been issued per our process. We just dont have any record of it being followed or completed. Nor does anyone else have record of it. So, I think we can say that the process was never followed in this case. And the person who posted the document simply didnt follow the process and posted it.

Also, its important to know here, that the BPR process can only be completed if first a new BPR form within SharePoint is initiated, so I think your right, but in reverse order.
 
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TacitBlue

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Okay, here is my revised 5 Whys, let me know if this is more clear and to the point...

Problem Statement:

ENG0002 Form G, Rev. D, does not show a BPR review number as required by DOC0013.

5 Why’s

WHY? The BPR review and approval process was not completed.

WHY? A new BPR form was never submitted for the document to initiate the BPR process.

WHY? A staff member bypassed the BPR process and posted the document directly to All Business Processes.

WHY? There was no secondary peer review to confirm that the BPR process was followed, as evidenced by the existence of a BPR form record and number. Additionally, there were no backup SharePoint alerts sent to other staff informing them that a document had been posted to All Business Processes.

WHY? (root cause) In DOC0013, there is no requirement for a secondary review by another person prior to uploading a document to All Business Processes, nor is there any requirement for alerts to be delivered to staff when a document is posted or changes are made to All Business Processes.
 

Miner

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Okay, here is my revised 5 Whys, let me know if this is more clear and to the point...

Problem Statement:

ENG0002 Form G, Rev. D, does not show a BPR review number as required by DOC0013.

5 Why’s

WHY? The BPR review and approval process was not completed.

WHY? A new BPR form was never submitted for the document to initiate the BPR process.

WHY? A staff member bypassed the BPR process and posted the document directly to All Business Processes.
I would agree up to this point. You should ask why they bypassed the BPR process. Was it too difficult? Were they unaware of it? ...?

WHY? There was no secondary peer review to confirm that the BPR process was followed, as evidenced by the existence of a BPR form record and number. Additionally, there were no backup SharePoint alerts sent to other staff informing them that a document had been posted to All Business Processes.
This is Issue #2. The lack of a peer review did NOT cause the person to bypass the BPR process. It may have allowed this to escape detection.

WHY? (root cause) In DOC0013, there is no requirement for a secondary review by another person prior to uploading a document to All Business Processes, nor is there any requirement for alerts to be delivered to staff when a document is posted or changes are made to All Business Processes.
This is what is called the systemic root cause i.e., what management system deficiency allowed Issue 1 and/or Issue 2 to occur.
 

TacitBlue

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I would agree up to this point. You should ask why they bypassed the BPR process. Was it too difficult? Were they unaware of it? ...?


This is Issue #2. The lack of a peer review did NOT cause the person to bypass the BPR process. It may have allowed this to escape detection.


This is what is called the systemic root cause i.e., what management system deficiency allowed Issue 1 and/or Issue 2 to occur.
 

TacitBlue

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Miner, I wish I knew how to answer the question of why that person bypassed the process. let's just say that the person was in full knowing of the process, but disregarded it, and pushed anyways. That person is no longer with our company, so above all, I cant answer this question. So, in that case, I am not sure how I can really objectively address the root cause.
 
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