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5-Whys on 3 Levels

John Predmore

Quite Involved in Discussions
There are potentially 3 paths in a Root Cause Analysis that give us 3 avenues to address a problem occurrence.

1. What happened that shouldn't have?
(how did this incident happen?)
direct causal sequence analysis

2. What shoulda happened that didn't?
(what quality checks or countermeasures should have triggered in this case but didn't, and why?)
mitigation strategy

3. What could be added to the process but wasn't?
(what practical countermeasures could have prevented or detected this happening, but was not in place?)
prevention is the best medicine strategy

If we do 5 Whys on 3 paths, that generates as many as 15 alternative interventions to consider, so a problem can almost definitely be mitigated or prevented in the future.
Once a quality problem occurs and escapes, this "5-Whys on 3 Levels" gives us the rhetorical "pound of cure".
The first item looks like the traditional application: "What happened that shouldn't have happened?" such as generation of nonconforming work.

The third looks like it supports the systemic root cause analysis called for by AIAG's CQI-20, Effective Problem Solving. Why didn't the planning process identify the issue ahead of time and prevent it?
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