Run 5 Whys Without Jumping
Apply evidence-based 5 Whys to identify a process root cause and escape point.
Nineteen packed kits were missing a required insert. The misses occurred only after a label-printer changeover on Line 2. Evidence-based 5 Whys: occurrence cause -> process cause -> escape point -> corrective control -> effectiveness check The common shortcut is to stop at operator missed the insert. That feels actionable because training is easy to assign, but it ignores the pattern after changeover and leaves the display-profile failure active. Why 1 Why were inserts missing? Operators packed kits without the insert prompt appearing on the pick display. The answer uses observed evidence: pick-display logs show the insert prompt was absent…
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