October 4, 2005 | Mark Paradies


I read all sorts of company newsletters and I saw one the other day that caused me concern.

It was from a company that had trained their “expert” investigators in TapRooT(R). These few experts (about 5) on the corporate staff were suppose to perform all the company’s root cause analysis.

But the company newsletter proclaimed a new “best practice.”

They had just discovered asking “Why” 5 times.

Now they were teaching all their workers to ask “Why” 5 times because:

“People can then do their own root cause analysis and

solve their own problems without help from the corporate staff.”

Is this a “best practice”?

I’ve explained in talks and articles why asking why 5 times (and other forms of cause-and-effect analysis) don’t work well, so I won’t repeat that here. Instead, let me emphasize the results I’ve seen when shop floor people are taught to “ask why” 5 times when performing investigations.


Sometimes people trained in this method get further beyond common blame that they practiced before their “5 Why” training. But the seldom get close to the root causes in the TapRooT(R) System. Instead, they often stop at symptoms that they solve with ineffective corrective actions.


Failed bearings became a root cause for an equipment failure and new bearings became the corrective action.

Human error (they just goofed up) became the root cause for mistake made by an operator and additional training became the corrective action.

Inappropriate behavior became the root cause of an operator not using a procedure and re-emphasize the need to use procedures became the corrective action.

These are all real examples.

NONE of the corrective actions fixed the real problems that had caused the original incident.

And all of the incidents occurred again – they were not “fixed”.

So when is a “good practice” a “bad practice”?

When people think they are improving performance and what they are actually doing is wasting effort, implementing ineffective fixes, and making management believe that progress is occurring when, in reality, they continue to misunderstand the causes of their problems. because they fail to fix real problems, they get ever closer to major failures that could:

– kill someone,

– cause major production losses,

– cause significant product quality issues,

– cause significant environmental damage

– lead to a public relation black eye, and/or

– cause hefty fines from a government regulator.

The serious accidents that occur prove that instead of being a good practice this “quick-and-dirty” analysis is actually a BAD PRACTICE.

To point out the facility of seeking time savings in critical business processes, I created “Spin-a-Cause” in the early 1990’s. If you haven’t seen it, click here.

It can be used to get management’s attention and impress them with the need for real, credible, thorough, systematic root cause analysis when analyzing problems that could lead to the types of failures mentioned above.

Management can always be tempted to take shortcuts and save effort. We all want to be as efficient as possible. But root cause analysis of serious business critical functions IS NOT the place to seek efficiency over effectiveness. As Albert Einstein said:

Everything should be made as simple as possible, but not simpler.”

Obviously, I believe that good (not just fast and easy) root cause analysis is needed to solve real problems. But I also understand that not every event deserves a full blown investigation. So what should you do? See the article about FASTER Investigations.

One last note.

The real “good practice” that this company missed is getting the right people trained to use real root cause analysis to solve problems and then provide them the time to do it right. This has been proven OVER AND OVER AGAIN to be the real time and money saver. For proof, click here to see the business success stories at the TapRooT(R) Web Site.

Root Cause Analysis
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