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§ 83Operations

Five Whys

The first answer to "why did this fail" is usually a symptom, and fixing a symptom leaves the cause in place to fail again.

Taiichi Ohno

Keep in mind

Keep asking why until you reach something you can change

What to do

In the postmortem, keep asking why of each answer until you reach something the team can change that would have stopped the chain, and give that change an owner. Branch whenever an answer has more than one cause, and never stop at a person: "the engineer made a mistake" is a cue to ask why the mistake was easy to make.

Why it happens

Investigations stop at the first cause that someone could plausibly have prevented, because it closes the ticket and names an action. That cause is usually the one nearest in time (a bad config push, a full disk), and fixing it removes this instance without touching whatever produced it. Asking why again of each answer walks the chain back to a condition (a missing check, a process nobody owns) whose fix prevents a whole class of failures. Five is a rule of thumb, not a required depth.

When it stops applying

Swiss Cheese Model: a single chain of whys picks one path through an accident that had several, the analyst's choice at each step decides which root cause comes out, and in complex systems there is often no single root to find.

Source

Taiichi Ohno, Toyota Production System: Beyond Large-Scale Production (Productivity Press, 1988; originally 『トヨタ生産方式』, Diamond, 1978), ch. 2 "Evolution of the Toyota Production System", section "Repeating Why Five Times" — the method as the basis of Toyota's approach to problems.

Read the source

Portrait: Toyota Motor Corporation company history editorial committee, Public domain in Japan · Wikimedia Commons

Cite this

Hammurabi, § 83, “Five Whys.” https://kanywst.github.io/hammurabi/laws/five-whys/

BibTeX
@misc{hammurabi-five-whys,
  title  = {Five Whys},
  author = {{Hammurabi contributors}},
  note   = {Hammurabi, § 83},
  url    = {https://kanywst.github.io/hammurabi/laws/five-whys/}
}

Text under CC BY-SA 4.0: credit Hammurabi and link the article.

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