Systems Thinking and The Five Whys

A Favorite Resource: The Fifth Discipline Fieldbook

FifthDiscFieldbookCoverLast week I was speaking with one of our new consultants about the importance of systems thinking, especially when solving problems, and I was reminded of one of my favorite resources, The Fifth Discipline Fieldbook (1994, Senge, Kleiner, Ross, et al.), and a customer story.

I love the fieldbook because it offers loads of great tools for helping leaders and teams improve their systems thinking skills. One of my favorite tools from the book, and one used commonly in Six Sigma circles, is the Five Whys.

N.B. – We’ll be discussing tools and models for becoming a better systems thinker at the North Bay Managers’ Forum. If you haven’t already registered, do it now.

A Word about Systems Thinking

So what do I mean by systems thinking?

OK, I admit it, I often look to Wikipedia for help defining concepts. I found a great definition there for systems thinking:

[Systems thinking, when applied to problem solving, is simply a way of] viewing problems as parts of an overall system, rather than reacting to specific parts, outcomes or events and potentially contributing to further development of unintended consequences.

Systems thinking is not one thing but a set of habits or practices within a framework that is based on the belief that the component parts of a system can best be understood in the context of relationships with each other and with other systems, rather than in isolation. Systems thinking focuses on cyclical rather than linear cause and effect.

Put more simply, systems thinking is a way of keeping the big picture in mind when solving problems and looking for solutions within a system, not in or by individuals. According to Peter Senge, “It is a framework for seeing interrelationships rather than things, for seeing patterns of change rather than static ‘snapshots’.”

The Five Whys in Two Stories

The five whys is particularly useful for hunting backwards for the root causes of recurring problems. It’s based in part on an established Japanese quality technique and its description by quality consultant Peter Scholtes.

The technique involves asking why five times, in a team setting, with discussion. It could involve any number of participants and is best done with an intact work team working on a real problem. It can also be done in pairs.

Story One – It’s the Gabungie By Golly

Here’s how I first heard about the Five Whys from Rick Ross. (I’ve taken a few liberties in the retelling.)

ShopFloorSpillIt’s 2:35 pm on a Tuesday, about an hour before the shift change at a local manufacturing plant, and Dave and Sarah are touring the plant.

Dave, the foreman, is helping Sarah, a new manager (and a systems thinker), learn about plant operations.

Suddenly, Dave sees a puddle of oil on the floor. He grabs the nearest member of the line crew and says, “Hey! There’s oil on the floor! For cryin’ out loud, somebody could slip on that and break their…! Would you clean that up?”

When Dave’s finished, Sarah (the systems thinker) breaks in with a quiet question, “Dave, why is there oil on the floor?”

“Yeah,” Dave repeats to the crew member. “How’d the oil get on the floor?”

The crew member replies, “Well, sir, the gabungie’s leaking.”

They all automatically look up. And, sure enough, there’s a visible leak up there in the gabungie.

“Er, okay,” Dave sighs. “Well, clean up the oil and get the gabungie fixed right away.”

Sarah pulls Dave aside and murmurs, “But, er, why is the gabungie broken?”

Dave says, “Yeah, well, the ga-” and turns to the crew member. “Why is the gabungie broken?”

“The gaskets are defective.”

“Oh well, then, look,” Dave says. “Here. Clean the oil up, fix the gabungie, and, uh, do something about the gaskets!”

Sarah adds: “And why are the gaskets defective?”

“Yeah,” Dave says. “Just out of curiosity, how is it we’ve got defective gaskets in the gabungie?”

The crew member says, “Well, we were told that purchasing got a great deal on those gaskets.”

Dave sees Sarah open her mouth, but this time he’s way ahead of her. “Why did purchasing get such a great deal?”

“How should I know?” says the crew member, wandering off to find a mop and a bucket.

Dave and Sarah return to Dave’s office and make some phone calls. Turns out the plant has a two-year-old policy in place that encourages purchasing at the lowest possible price. Hence the defective gaskets (of which there is a five-year supply) along with the leaking gabungie and the pool of oil.

In addition, this policy is almost certainly causing other problems throughout the organization, not closely related in time or space to the root “cause.”

Story Two – The Customers Are Walking Away

Here’s a version of the Five Whys that’s a little closer to home. It’s from one of our clients. (I’ve fictionalized several details of this story in order to abbreviate it and protect privacy.)

A few months back I was working with a project team assigned to address a sales problem. The client-organization had put a lot of effort behind a sales initiative over previous months and in most cases things were going well. In one particular region, however, they were not seeing the bump in sales they were expecting. All signs were pointing to a boost — they had seemingly done all the right things — but the sales just weren’t happening.

The Sales Process

Our client-organization had arranged to sell their services through a large retailer. They had placed trained sales reps in retail outlets in order to make personal connections with potential customers.

Here’s a simplified model of the sales process:


  1. In-Store Rep engages with prospect, holds engagement conversation, qualifies prospect
  2. In-Store Rep secures commitment from prospect to speak with Sales Rep over the phone within two business days
  3. In-Store Rep walks with customer to department kiosk and enters customer contact information
  4. Sales Rep contacts customer by phone
  5. Sales Rep explains service in greater detail, answers questions, sells new contract

The First Why: Why are sales lower in this region?

In our analysis we discovered that sales were happening at a reasonable level in most regions, but not in this one particular region. We wanted to know what was behind this.

We explored details and discovered that skill levels of the in-store reps were roughly equivalent to other regions. We also discovered that, given the customer population, in-store reps were holding a reasonable number of engagement conversations and gaining commitments with qualified customers (Steps 1 and 2).

There appeared to be a breakdown between Steps 2 and 3 — reps were not entering customer information at the kiosks as frequently as they should have been.

The Second Why: Why are reps unable to get from commitment (Step 2) to information entry (Step 3)?

PeopleAtKioskThe project team interviewed reps and discovered rather quickly that in many cases the reps could not keep customers at the kiosks long enough to enter their information. Turns out customers were extremely busy and usually in a rush. They were often just “popping in” to the store on their days off and, while they may have had interest in the service and had answered Yes to the commitment question, many walked away before the rep could enter their information.

The Third Why: Why are customers walking away?

Turns out it took a very long time to enter customer information in the system. It took almost five minutes from the time the rep touched the screen to the time they were able to enter the first name of the customer. In retail, five minutes can be an eternity. Customers would give up and walk away. Sometimes, even when reps collected customer information on paper, the rep would forget to enter or give up on entering the info because of the delays.

The Fourth Why: Why did it take so long to enter customer information?

We had been so focused on helping sales reps learn to build consultative selling skills and use the customer information entry form, we had not stopped to examine what happened at one of the most important parts of the process: the activity between (a) the moment the rep touched the screen at the department kiosk and (b) when the customer information form (CIF) appeared.

In most regions, this was not a problem. But in this particular region, the reps had two things working against them:

  1. The customer information form (CIF) was buried so far down in the system menu that it was hard to find.
  2. The form was accessed remotely which made for remarkably slower load times.

It was at this point that most of the problems were solved. The project team worked with the region’s IT team to move the CIF link to the top level of the kiosk’s user interface and relocate the form so it was accessed locally. The collection of customer information now took seconds instead of minutes and qualified customers were no longer walking away.

The Fifth Why: Why was the CIF so difficult to get to?

There were several answers to this question, but these are the two we deemed most important:

First, this region had recently undergone some rather severe layoffs and the IT team had been heavily affected.

At the time of the configuration discussions focused on the the CIF, the region’s IT team was not represented (and no one from our team caught it). They had someone create access to the CIF form for their stores at the last minute and with virtually no guidance from headquarters.

There were certainly other additional unintended consequences as a result of these cuts.

The second answer was an important lesson for the project team. We did not check CIF access at kiosks at all regions. For future implementations, the team added a double-check into the process that helps them confirm smooth functioning of every technical component along the sales process.

How to Use the Five Whys as an Exercise

Planning to try this out yourself? The Fifth Discipline Fieldbook offers a few recommendations on how to apply the Five Whys.

Here’s our version of it, edited slightly from Ross’ original:

Step 1 – Choose a Knotty Problem and a Symptom within that Problem

Choose a pernicious, recurring problem and pick the symptom where you wish to start; the thread which you hope you can pull on to unravel the knot.

SystemicExplanations2Step 2 – Ask the First Why

Ask “Why is such-and-such taking place?” You will probably end up with three or four answers. Post them on the wall or a whiteboard with plenty of room around them.

Step 3 – Ask the Successive Whys

Repeat the process for every statement on the wall, asking “Why” about each one. (It doesn’t have to be exactly five whys — ask as many or as few as you need to.) Post each answer near its “parent.”

Follow up all the answers that seem likely. You will probably find them converging; a dozen separate symptoms may be traceable back to two or three systemic sources.

As you trace the Whys back to their root causes, you will find yourself grappling with issues that not only affect the gabungie (whatever that may be), but the entire organization. The policy to get the lowest price on supplies might have been caused by a battle in the finance office. It might result from a purchasing strategy, or from underinvestment in maintenance. The problem is not that the original policy was “wrongheaded,” but that its long-term and far-flung effects remained unseen.

Avoid “Fixating on Events”

To be effective, your answers to the Five Whys should steer away from blaming individuals. For example, in answer to the question: “Why is there oil on the floor?” someone may say:

    • “Because the maintenance crew didn’t clean it up.”
  • “Why didn’t they clean it up?”
    • “Because their supervisor didn’t tell them to.”
  • “Why didn’t he do that?”
    • “Because the crew didn’t tell him about it.”
  • “Why didn’t they tell him?”
    • “Because he didn’t ask.”

Note that blaming individual people leaves you with no option except to punish them; there’s no chance for substantive change.

One of the benefits of the Five Whys exercise is that it encourages people to recognize the difference between an event-oriented explanation, and a systemic explanation. The systemic explanations are the ones which, as you trace them back, lead to the reasons why they didn’t clean it up, or he didn’t tell them to, or they didn’t ask. (Maybe, for example, poor training of maintenance people contributed to the oil puddle problem; but even the best-trained, hardest-working custodians in the world could not stop the gasket from leaking.)

To avoid being distracted by event- and blame-related “answers,” try this technique: as each answer is recorded, say: “Okay. Is that the only reason?”

Check out The Fifth Discipline Fieldbook for more on systems thinking.

To discuss the Five Whys and other useful systems thinking tools, come join us at the North Bay Managers Forum.

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Posted in: Consulting, Creativity, Evaluation, Innovation, Learning Organizations, Manager Tips, Performance, Systems Thinking, Tools

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