A Kingdom lost for a nail

“For the want of a nail the shoe was lost,
For the want of a shoe the horse was lost,
For the want of a horse the rider was lost,
For the want of a rider the battle was lost,
For the want of a battle the kingdom was lost,
And all for the want of a horseshoe-nail.”

Read this in reverse and it makes a splendid illustration of the “5 Why’s” process. A team recently illustrated this process as follows. We had unusually high contamination levels in tissue culture – a biological process in which a plant is regenerated from cells in a petri-dish.

WHY did we observe contamination?

BECAUSE of fungal spores in the lab environment where tissue culture was performed.

WHY did we have fungal spores in the lab environment?

BECAUSE the neighboring entomology lab that works with insects had washed their trays in an adjacent space. The team had used these trays to feed pests a nutrient-rich diet for entomologic assays. Fungal contamination is common and harmless as mold on bread. In the process of cleaning and drying trays, they had released fungal spores to the environment and they had moved through the ventilation systems.

WHY did they wash their trays in the neighborhood for the first time?

BECAUSE warm weather had meant high incidence of pests in the country leading to a spike in work for the entomologists. Loaded with work, they had chosen to do the cleaning of trays in the main building rather than the annex, where the work was usually done.

So, it took three why’s to get to the root cause. A lab technician had observed the deviation from practice, Applying “5 Why’s” and involving the team mean the cause could be connected to the effect and the problem fixed.

band aid

How often do we apply a band-aid to the problem and think we have done our job? Lean Six-Sigma has a repertoire of techniques that help break old ‘lazy’ habits and replace then with new ones. They make work interesting and improve employee engagement.


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