five whys

is a system level analysis such that if a mistake happens, then shame on the management for making it so easy to make that mistake.

When blame inevitably arises, the most senior people in the room should repeat this mantra: if a mistake happens, shame on us for making it so easy to make that mistake. In a Five Whys analysis, we want to have a systems-level view as much as possible.

is a way of encouraging risks, because any harm to the system reveals its fragility, which is a problem that requires addressing.

For engineers trained in traditional development methods, this was often frightening. They would ask, 'What will happen to me if I accidentally disrupt or stop the production process'' In their previous jobs, that was a mistake that could get them red. At IMVU we told new hires, 'if our production process is so fragile hat you can break it on your very first day of work, shame on us for making it so easy to do so.' If they did manage to break it, we immediately would have them lead the effort to fix the problem as well as the effort to prevent the next person from repeating their mistake.

is a way of getting the team started making proportional investments in prevention.

The first rule encourages people to get used to being compassionate about mistakes, especially the mistakes of others. Remember, most mistakes are caused by flawed systems, not bad people. The second rule gets the team started making proportional investments in prevention.

is a way of growing to recognize that most mistakes are caused by flawed systems, not bad people.

is an investigative method of asking the question 'why'' five times to understand the root cause of a problem in a system.

The alternative is to use a system called the Five Whys to make incremental investments and evolve a startup's processes gradually. The core idea of Five Whys is to tie investments directly to the prevention of the most problematic symptoms. The system takes its name from the investigative method of asking the question 'Why'' five times to understand what has happened (the root cause). If you've ever had to answer a precocious child who wants to know 'Why is the sky blue'' and keeps asking 'Why'' after each answer, you're familiar with it. This technique was developed as a systematic problem-solving tool by Taiichi Ohno, the father of the Toyota Production System. I have adapted it for use in the Lean Startup model with a few changes designed specifically for startups. At the root of every seemingly technical problem is a human problem. Five Whys provides an opportunity to discover what that human problem might be. Taiichi Ohno gives the following example: When confronted with a problem, have you ever stopped and asked why five times' It is difficult to do even though it sounds easy. For example, suppose a machine stopped functioning: 1. Why did the machine stop' (There was an overload and the fuse blew.) 2. Why was there an overload' (The bearing was not sufficiently lubricated.) lubricated.) 3. Why was it not lubricated sufficiently' (The lubrication pump was not pumping sufficiently.) 4. Why was it not pumping sufficiently' (The shaft of the pump was worn and rattling.) 5. Why was the shaft worn out' (There was no strainer attached and metal scrap got in.) Repeating 'why' five times, like this, can help uncover the root problem and correct it. If this procedure were not carried through, one might simply replace the fuse or the pump shaft. In that case, the problem would recur within a few months. The Toyota production system has been built on the practice and evolution of this scientific approach. By asking and answering 'why' five times, we can get to the real cause of the problem, which is often hidden behind more obvious symptoms.

is conducted most effectively when absolutely everyone involve is in in the room so as to avoid them becoming the target for blame.

I recommend several tactics for escaping the Five Blames. The first to make sure that everyone affected by the problem is in the room during the analysis of the root cause. The meeting should include anyone who discovered or diagnosed the problem, including customer service representatives who fielded the calls, if possible. It should include anyone who tried to fix the symptom as well as anyone who worked on the subsystems or features involved. If the problem was escalated to senior management, the decision makers who were involved in the escalation should be present as well. This may make for a crowded room, but it's essential. In my experience, whoever is left out of the discussion ends up being the target for blame. This is just as damaging whether the scapegoat is a junior employee or the CEO. When it's a junior employee, it's all too easy to believe that that person is replaceable. If the CEO is not present, it's all too easy to assume that his or her behavior is unchangeable. Neither presumption is usually correct.

is not just about driving out superficial waste, but more broadly, it develops a new understanding of how to work together.

On the surface, Five Whys seems to be about technical problems and preventing mistakes, but as teams drive out these superficial wastes, they develop a new understanding of how to work together. Tony put it this way: 'I daresay that I discovered that the Five Whys transcends root cause analysis by revealing information that brings your team closer through a common understanding and perspective. A lot of times a problem can pull people apart... Five Whys does the opposite.'

is a set of questions that requires an environment of mutual trust and empowerment. In situations in which this is lacking, the complexity of five whys can be overwhelming.

For the Five Whys to work properly, there are rules that must be followed. For example, the Five Whys requires an environment of mutual trust and empowerment. In situations in which this is lacking, the complexity of Five Whys can be overwhelming. In such situations, I've often used a simplified version that still allows teams to focus on analyzing root causes while developing the muscles to focus on analyzing root causes while developing the muscles they'll need later to tackle the full-blown method. I ask teams to adopt these simple rules: 1. Be tolerant of all mistakes the first time. 2. Never allow the same mistake to be made twice.

five whys, n.Definitions

five whys