---
title: 3x5 Why
tags: ZF
---
# Script - 3x5 Why
## Scene 1 - The Mysterious Red Rash
### Slide 1.1
Welcome to the Training "3x5 Why".
Click start to begin with the training.
### Slide 1.2
Chapter 1
**The Mysterious Red Rash**
### Slide 1.3
**An Unexpected Problem**
A major American airline experienced a mysterious, unexpected problem. The mystery started on February 1st after the purchase of several additional A300 Airbus aircraft, which would open a new transatlantic flight route from New York to Frankfurt. Reports surfaced that flight attendants on these planes were developing an ugly and irritating, red rash on their face, hands, and neck. The rash seemed to appear about 45 minutes into the flight; just as the plane reached cruising altitude of 31,000ft. And it disappeared just as quickly as it appeared – almost exactly three hours later.
The problem occurred regularly on the new transatlantic route. 3 out of the 10 flight attendants on these flights reported the red rash. No passengers nor the pilot or flight deck crew developed the red rash.
### Slide 1.4
The airline had already been using the A300 Airbus for domestic flights since last July. No reports of the rash were recorded on these domestic flights. The domestic and transatlantic flights have the same cruising altitude of 31000ft. Contrary to domestic flights, the transatlantic flights require additional safety instructions for life vests and oxygen masks and an additional foods and drinks service. Both the safety instructions and the foods and drinks services were regularly attended to by the same 3 flight attendants.
Despite different desperate approaches to end the problem, the rash continued unabated.
A Federal Judge was threatening to ground the fledgling Airbus until proof was forthcoming that the rash wasn't toxic and long-term effects were non-existent.
Can you help the airline to solve this mystery?
### Slide 1.5
Your Guess?
*[Interaction:]*
What is the cause for the red rash?
*[free text field]*
Hint: If you are not yet able to provide the correct answer, you might as well have a guess or just move on.
### Slide 1.6
**The Right Approach**
You may have had difficulties in answering the question right now.
At this point we can see it is very difficult to identify the true cause for the red rash. And even if you guessed the cause right, you might have overlooked important details that are needed to reliably fix the issue.
To solve the red rash mystery, we need to act like a good detective.
### Slide 1.7
The first step would be to describe the problem with all the information we have.
Next we will do a structured analysis of what happened based on our problem description.
And finally we will hopefully solve this mystery.
## Scene 2 - Problem Description
### Slide 2.1
Chapter 2
**Problem Description**
### Slide 2.2
We can generate a problem description in three simple steps.
Ask the Right Questions
Answer the Questions
And finally Generate the Problem Description
### Slide 2.3
**Step 0: Starting Point**
To generate the problem description, we need a starting point.
The starting point is a negative effect that can be either a metric (e. g. a customer complaint, scrap, downtime) or unexpected cost.
The effect in our case: A judge threatening to shut down flight operations.
The next three steps are for defining the problem description.
### Slide 2.4
**Step 1: Ask the Right Questions (5W1H)**
As a first step, we collect information about our problem.
To do this, we should ask the following questions:
What? Where? When? Who? How? and Which?
| 5W + 1H | Questions |
| -------- | -------- |
| What? | What object? |
| What? | What Defect? |
| Where? | Where was the object? |
| Where? | Where is the defect in the object? |
| When? | When was the first time this problem was observed (date / time)? |
| Who? | Who found the defect? |
| How? | How many objects? |
| How? | How big is the defect in the object? |
| Which? | Is there a trend? |
### Slide 2.5
**Step 2: Answer the Questions (Is - Is Not)**
..
As a second step, we will answer our questions. For this purpose, we will use a matrix.
In the first column we fill in our six questions.
In the second column, we answer these questions by describing what "is" part of the problem.
In the third column, we answer the same questions by describing what "is not" part of the problem.
Therefore, this method is also known as the Is - Is Not method.
*[Text]
Hint: When inserting the IS and IS NOT information in your table, it is important to compare apples with apples. This means that you try to fill in information in the IS NOT column that is comparable and similar to the information in the IS column. For example if you describe that your object is a green apple, it would be helpful to state that your problem IS NOT a red apple. To state that your problem is not a bicycle would be correct, too. However, this information is not comparable or similar to an apple - therefore it is not helpful for solving a problem.
Thinking about what our problem IS NOT about also helps us to fill in precise information in the IS column.*
| 5W + 1H | Questions | IS | IS NOT |
| -------- | -------- | -------- | -------- |
| What? | What object? |
| What? | What Defect? |
| Where? | Where was the object? |
| Where? | Where is the defect in the object? |
| When? | When was the first time this problem was observed (date / time)? |
| Who? | Who found the defect? |
| How? | How many objects? |
| How? | How big is the defect in the object? |
| Which? | Is there a trend? |
### Slide 2.6
*[Interaction]*
Please drag and drop the answers to the correct place in the IS - IS Not Matrix.
*[drag & drop elements to be defined]*
| 5W + 1H | Questions | IS | IS NOT |
| -------- | -------- | -------- | -------- |
| What? | What object? | Flight attendants | Other flight attendants, passengers, crew |
| What? | What Defect? | An ugly and irritating red rash | Other skin or health issues |
| Where? | Where was the object? | At 31,000 feet high | Between 0 and 30,999 feet |
| Where? | Where is the defect in the object? | On the face, hands and neck | Does not cover the rest of the body |
| When? | When was the first time this problem was observed (date / time)? | On February 1st after the purchase of several additional A300 | Before February |
| Who? | Who found the defect? | Flight attendants | Other flight attendants, passengers, crew |
| How? | How many objects? | 3 | Other flight attendants (7), passengers, crew |
| How? | How big is the defect in the object? | Covers 20% of the body (the face, hands and neck) | Does not cover the rest of the body (80%) |
| Which? | Is there a trend? | Between 0.75 hours and 3.75 hours after departure on transatlantic flights | From 0 hours to 0.75 hours and after 3.75 hours on transatlantic flights; not on domestic flights |
### Slide 2.7
**Step 3: Generate the Problem Description**
As a third step, we generate a compact problem description out of the IS column of our matrix.
**Problem Description**:
“3 Flight attendants with an ugly and irritating red rash that covers the face, hands and neck at an altitude of 31,000 feet that lasts 3 hours on transatlantic flights and started on February 1st.”
This problem description is also often referred to as the failure mode.
## Scene 3 - Structured Analysis
### Slide 3.1
Chapter 3
**Structured Analysis**
### Slide 3.11
Now that we have our problem description, we can continue with a structured analysis.
For the analysis we will proceed in three steps as well.
The first step is to choose an Analysis Method.
The second step is to do the analysis and identify possible causes.
And the final step is to examine and verify the possible causes.
### Slide 3.2
**Step 1: Choose an Analysis Method**
Based on our problem description we can aim to identify possible causes by using problem solving techniques.
For solving the mystery of the red rash we will use a timeline and a process flow diagram.
### Slide 3.3
**Step 2: Do the Analyses and Identify Possible Causes**
We will start with a timeline first.
In a timeline we display the most important changes which were made in the time period before the problem occurred for the first time.
From the timeline we learn that the airline purchased new food and drink trolleys, new snack trolleys and new safety instruction equipment. All equipment was purchased from the same supplier as before.
```flow
st=>start: Start
e=>end: End
op=>operation: Last five years (and ongoing)
Airbus A300 is used for domestic flights
op2=>operation: January 15th
Acquisition of new equipment:
- food and drink trolleys
- snack trolleys
- safety instruction equipment
op3=>operation: February 1
- First appearance of red rash
- First day of the two-week training period with plane model A380 for new transatlantic flight route
op4=>operation: February 15
- Purchase of new air filtration system (same supplier as before)
st->op->op2->op3->op4->e
```
### Slide 3.4
After the timeline we will now continue with the Process Flow Diagram.
The process flow diagram allows us to see the array of different procedures that take place on an A300 flight.
It also allows us to compare the transatlantic flights with the domestic flights. This means that we compare a process indicating the problem with a process which is free of this problem.
**Domestic Flights**
```flow
op=>operation: Take-off
op2=>operation: Cruising altitude at 31000ft
op3=>operation: Safety instructions
Seatbelts / Masks
op4=>operation: Snacks
Cookies / Almonds / Water, Juice, Softdrinks
op5=>operation: Preparation for landing
op->op2->op3->op4->op5
```
**Transatlantic Flights**
```flow
op=>operation: Take-off
op2=>operation: Cruising altitude at 31000ft
op3=>operation: Safety instructions
Seatbelts / Masks / Life vest
op4=>operation: Food and Drinks service
Sandwich / Salad / Water, Juice, Softdrinks
op5=>operation: Snacks
Cookies / Almonds / Water, Juice, Softdrinks
op6=>operation: Preparation for landing
op->op2->op3->op4->op5->op6
```
### Slide 3.5
Comparing the two process flow diagrams we can see that the snacks are part of both the transatlantic and the domestic flights.
Therefore, they cannot be the cause of the red rash, as the red rash does not appear on domestic flights. We can now eliminate the recently acquired snack trolleys as a possible cause.
However, the safety instructions for life vests and oxygen masks and the foods and drinks service are only part of the transatlantic flights. This means that we have to have a closer look at the recently purchased food and drink trolleys and safety instruction equipment.
### Slide 3.6
**Step 3: Examine and Verify the Possible Causes**
As we identified two process differences - and thereby two possible causes for the red rash - we can now examine them.
Our goal is to verify if one of these process differences can cause the red rash.
For this reason, we go back to our matrix. We verify the assumed cause by analyzing if it matches the Is and Is Not description.
### Slide 3.7
Here we ask a question for each line of the matrix. The question validates if our assumed cause is true for each aspect of the matrix.
The question always starts the same way.
*[Text]*
*If the food and drinks service was the real cause, would I expect: ...*
At the end of the question, we insert the specific content from a line in the matrix.
*[Text]*
*... 3 flight attendants with an ugly irritating red rash at 31,000 feet high but not between 0 and 30,999 feet?*
The answer would be yes. The food and drinks service takes place at a flight altitude of 31,000 feet, as we could see in the process flow chart.
### Slide 3.8
Let’s examine a second example:
*[Text]*
*“If the food and drinks service was the real cause, would I expect: 3 flight attendants with an ugly irritating red rash which covers approximately 20% of the body, including the face, hands and neck, but not the rest of the body?”*
The answer would be no. The hands can come into contact with the food and drinks, but that’s not true for the face and neck.
### Slide 3.9
*[Interaction]*
Now it’s your turn! Please verify if the safety instructions for life vests could be the cause for the problem.
Please decide whether the affirmative answer should be yes or no.
[user has to select “yes” for each line; after “yes” is selected, the reasoning pops up automatically]
Congratulations! As you could answer all questions with “yes”, you have found the cause for our problem.
*[Text]*
*Hint: If we would not have been successful with verifying one of the causes we found with the help of our process flow diagram, we now would have to use another problem solving technique to generate new possible explanations.*
| Questions | IS | IS NOT | Affirmative Answer | Reasoning |
| -------- | -------- | -------- | -------- | -------- |
| What object? | Flight attendants| Other flight attendants, passengers, crew |
| What Defect? | An ugly and irritating red rash | Other skin or health issues |
| Where was the object? | At 31,000 feet high| Between 0 and 30,999 feet | Y | The instructions are executed when the plane reaches the cruising altitude of 31,000 feet |
| Where is the defect in the object? | On the face, hands and neck | Does not cover the rest of the body | Y | The demonstration equipment (masks, and life jackets) has contact with hands, face, necks but not with legs and feet |
| When was the first time this problem was observed (date / time)? | On February 1st after the purchase of several additional A300s| Before February| Y | Food and drinks service was introduced on February 1st, right after the purchase of several additional A300s when the traffic on the new transatlantic route started. |
| Who found the defect?| Flight attendants | Other flight attendants, passengers, crew | Y | Only flight attendants doing the safety instructions come into contact with the life vests |
| How many objects? | 3 | Other flight attendants (7), passengers, crew | Y | Only the 3 flight attendants doing the safety instructions come into contact with the life vests |
| How big is the defect in the object? | Covers 20% of the body (the face, hands and neck) | Does not cover the rest of the body (80%) | Y | The demonstration equipment (masks, and life jackets) has contact with hands, face, necks but not with legs and feet |
| Is there a trend? | Between 0.75 hours and 3.75 hours after departure on transatlantic flights | From 0 hours to 0.75 hours and after 3.75 hours on transatlantic flights; not on domestic flights | Y | Only on transatlantic flights is the life jacket used as demonstration equipment; the rash starts after approx. 0.75 hours of the flight and disappears 3 hours later |
### Slide 3.10
One Moment, Please ...
Did we really detect the true cause or did we just observe a symptom?
To truly understand in detail what happened and how we can prevent the red rash from occuring again, we have to dive deeper in what exactly happened.
When we again compare our problem solving procedure to how a good detective works, we can look at it this way:
So far, we found out who committed the crime, but we did not yet find out what his motive was and how exactly he did it.
Of course, we want to fully solve and understand our red rash mystery.
You will have the opportunity to do this in the next chapter of this training!
## Scene 4 - 3x5 Why
### Slide 4.1
Chapter 3
**3x5 Why**
### Slide 4.2
In this chapter we will examine the red rash more closely. For this purpose, we will use the 3x5 Why analysis.
### Slide 4.21
The principle behind 3 x 5 Why is simple:
The 3 stands for the three different angles from which a problem can be considered. These angles are called the occurence leg, the detection leg and the systemic leg.
*[Text]*
***Occurrence leg**: For which technical reason did the problem occur?*
*[click to reveal: “See example”: For which specific technical reason did the life vest and oxygen mask cause the red rash?]*
***Detection leg**: Why was the problem not detected?*
*[click to reveal: “See example”: Why did the routine controls of airline safety equipment not detect the problem before it happened?]*
***Systemic leg**: Why was the problem not prevented?*
*[click to reveal: “See example”: Why was the problem not prevented despite the fact that the airline has health compatibility checking routines for safety equipment?*
### Slide 4.3
The 5 Why stands for asking “Why” continuously until you have found the root cause for the problem. Depending on the individual leg you consider a specific aspect of the problem. Then you keep asking why until you have found the root cause. On average, you have to ask Why five times until you find the root cause - however, it can also be more or less.
### Slide 4.4
The “x” symbolizes that these 3 legs and 5 Whys are combined. Therefore we will now regard all 3 legs one by one. In each leg, we will keep asking why until we find the root cause.
### Slide 4.5
**Leg 1: Occurrence leg**
In the occurrence leg, we ask: “for which technical reason did the problem occur?”
We start our “Why” analysis with the problem effect. After asking Why for the first time, the problem description follows.
The root cause we are searching for has to be a technical description
*[Text]*
**Question**:
for which technical reason did the problem occur?
**Starting Point**:
problem effect -> why -> problem description = failure mode
**Root Cause**:
technical reason
```mermaid
graph TD
A[Effect<br>federal judge was threatening to shut down Airbus operations] -->|Why?| B[Failure Mode<br>3 flight attendants with an ugly and irritating red rash that covers the face, hands and neck lasting 3 hours at 31,000 feet of altitude on transatlantic flights and started on February 1st] --> |Why?| C[use of life jackets during the safety instructions caused skin irritations] --> |Why?| D[Occurrence Root Cause<br>Technical Reason<br>safety instruction demonstration jackets are labelled with a litholrubine chrome molybdate orange pigment]
```
### Slide 4.6
**Explanation**
As you can see, through asking why, while looking for a technical root cause, we finally found it. Now we can understand much better how the life jackets could cause the red rash.
### Slide 4.7
**3x5 Why Test Procedure**
To check whether our reasoning applying “3x5 Why” makes sense, we can verify our explanations backwards.
This means that we move from the root cause to the effect.
In this case, we use “therefore” instead of “why” to link the boxes.
*[Text]*
Example:
**ROOT CAUSE** - safety instruction demonstration jackets are labelled with a litholrubine chrome molybdate orange pigment
THEREFORE :arrow_forward: the use of life jackets during the safety instructions caused skin irritations
THEREFORE :arrow_forward: **FAILURE MODE** - there were 3 flight attendants with an ugly and irritating red rash that covers the face, hands and neck at 31,000 feet of altitude that lasts 3 hours on transatlantic flights and started on February 1st.
THEREFORE :arrow_forward: **EFFECT** - the federal judge was threatening to shut down Airbus operations.
Hint: This “therefore” test works for all 3 legs
### Slide 4.8
**Leg 2: Detection Leg**
In the detection leg, we ask: “why was the problem not detected?”
We start our “Why” analysis with the failure mode.
The root cause we are searching for can be any type of reason.
*[Text]*
**Question**:
Why was the problem not detected?
**Starting Point**:
failure mode (= our problem description)
**Root Cause**:
any type of reason
```mermaid
graph TD
A[Failure Mode<br>3 flight attendants with an ugly and irritating red rash that covers the face, hands and neck lasting 3 hours at 31,000 feet of altitude on transatlantic flights and started on February 1st] -->|Why did the airline not detect the problem before it occurred? ?| B[when the safety demonstration equipment with the problematic orange pigment were introduced on January 15th the issue was not detected] --> |Why?| C[Detection Root Cause<br>health tolerability checking routine was not used because the new model from the same manufacturer only had cosmetic changes - new orange pigment]
```
Hint: in the detection leg, one or several root causes can be found.
### Slide 4.9
**Leg 3: Systemic Leg**
In the systemic leg, we ask: “why was the problem not prevented?”
We start our “Why” analysis with the systemic root cause from the first leg.
The root cause we are searching should be an incomplete routine or process from the organization.
*[Text]*
**Question**:
Why was the problem not prevented?
**Starting Point**:
root cause from occurence leg (=leg 1)
**Root Cause**:
incomplete routine or process
```mermaid
graph TD
A[Occurrence Root Cause - Technical Reason<br>safety instruction demonstration jackets are labelled with a litholrubine chrome molybdate orange pigment] -->|Why did our systems not prevent the Safety instruction demonstration jackets to be labelled with a litholrubine chrome molybdate orange pigment? | B[orange pigment was not restricted to come into contact with humans] --> |Why?| C[orange pigment was not included in the airline's list of prohibited substances] --> |Why?| D[list of prohibited substances has not been updated in the last 3 years]
```
## Scene 5 - 3x5 Why Follow-up
### Slide 5.1
Chapter 5
**3x5 Why Follow-up**
### Slide 5.2
Through completing the 3x5 Why analysis, we have found at least 3 different root causes:
* a technical root cause (can be an interaction with another technical root cause)
* one or several detection root causes
* one or several systemic root causes
Of course, we want to reliably fix the problem and prevent it from happening again.
Therefore corrective actions are now taken.
Their aim is to update existing processes in a way so that this or a similar problem cannot happen again.
### Slide 5.3
This table shows the corrective actions which are to be done for each root cause we found in our three legs:
| Leg | Question| Root Cause | Corrective Actions |
| -------- | -------- | -------- | -------- |
| 1 Technical | Why did the problem happen? |**Technical**<br>Example: safety instruction demonstration jackets are labelled with a litholrubine chrome molybdate orange pigment | - correct technical failure<br>- check and update PFMEA|
| 2 Detection | Why did we not detect the problem? | **Any type of cause**<br>Example: health tolerability checking routine was not used because the new model from the same manufacturer only had cosmetic changes (new orange pigment)| - correct detection cause<br>- check and update control plan |
| 3 Systemic | Why did we not prevent the problem? | **System / Routine / Process**<br>Example: list of prohibited substances has not been updated in the last 3 years | - check and update work instructions, work routines, internal audits
*[Control plan: document which shows detection risks and how to prevent them]*
*[PFMEA: document which shows process risks and how to prevent them]*
*[Text]*
Hint: To explain all the corrective actions in detail is not part of the scope of this training, as they are again separate and often complex methods.
### Slide 5.4
**The Solution to the Mysterious Red Rash**
Of course, the airline which experienced the red rash problem also did the obvious to fix the technical reason for the problem:
* The airline exchanged the safety demonstration equipment
### Slide 5.5
Moreover, they implemented additional corrective actions leading to improved processes:
From now on ...
* only safety demonstration equipment with skin-friendly pigments was used
* health tolerability checking routines were also used after minor product changes (also for cosmetic changes)
* and the list of prohibited substances was updated at least every 6 months
### Slide 5.6
In this training you have seen the importance of creating a good problem description and analyzing the problem in a structured way.
Moreover, you have got to know the benefits of using 3x5 Why for fully understanding different important aspects of a problem.
As the airline implemented all corrective actions, the mysterious red rash never occurred again.
The airline’s flight attendants, the passengers and the federal judge were pleased with the solution.
Thank you for participating in this training and goodbye!
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