The 5-Why and Church Harm

The 5-Why and Church Harm December 4, 2023

The 5-Why and Church Harm

The 5-Why and Church Harm
Photo by Andrea Piacquadio – Pexels

In the 1930s, the Japanese industrialist Sakichi Toyoda (the inventor of Toyota) developed “The Five Why System.”  The method is remarkably simple: when a problem occurs, you drill down to its root cause by asking “Why?” five times. Then, when a countermeasure becomes apparent, you follow it through to prevent the issue from recurring.[1]  The following chart, by Easy Retro, identifies how this process works:[2]

When I experienced using this root cause determination process, the managers and supervisors often didn’t like it because it sometimes pointed not to customer or employee error but to their own issues in managing the business. This is an example where too many accidents occur.


Management assumes that millennials don’t care and the employees are being careless or rebellious.

Define the problem: We are experiencing twice as many accidents (one issue at a time).

1. Why are there more accidents?

After interviewing people, observing processes, and reviewing records, we conclude that there are more accidents because employees are not following the safety procedures.

2. Why are employees not following the safety procedures?

After interviews and observations, we determined they were not following the safety procedures because they did not know the safety procedures.

3. Why do they not know the safety procedures?

After investigating some of the proposed ideas, interviewing more people, and observing more records, we determined that the reason they did not know the safety procedures was that they had not completed the required safety classes.

4. Why did the employees not complete the safety classes?

From the records we had previously gathered, it was determined that, for about a year, first-line supervisors routinely excused employees from safety classes to make production goals.

5. Why did supervisors excuse employees from safety classes to make production goals?

We interviewed production supervisors and determined that top management met about a year ago and communicated important priorities. Production was #1. Safety was number #2. They wanted the top objectives to be considered together, but when these goals were released in a memo, supervisors interpreted that the first was more important than the second. The Root Cause: Organizational priorities were poorly communicated by upper management


Why were there more accidents? Because employees were not following the safety procedures. Why? Because they did not know the safety procedures. Why? Because employees had not completed the safety classes. Why? Because the supervisors routinely excused them from training to meet production goals. Why? Root Cause: Priorities were not effectively communicated through the chain of command.

This is the point in the conversation where all quality assurance team members look at each other and communicate with their eyes, “Who is going to tell them?” “I’m not going to tell them.” Upper management certainly wants to reduce injuries, just like churches want to reduce the number of people harmed by what they do as an organization. But, often, the root cause of harm in the church is not just because individual church members are careless. Usually, there is a deeper root cause for everything.

Things don’t just happen in a vacuum; we live in a cause-and-effect universe. And we can’t just say that sin is the root cause of everything because it can be drilled deeper by asking, “Why?” I warn you that if you do a 5-Why on church harm, you may be surprised at what you find if you do it honestly.

The “5 Why” method uses countermeasures, sometimes called corrective actions, instead of solutions. We have all been in situations inside the church where solutions that didn’t solve the root cause were determined. Corrective, or countermeasures, are “actions aimed at removing the cause of nonconformities to prevent their future recurrence.”

Sure, an organization can fire employees or even first-line supervisors because they’re having too many accidents, but only when they address the root cause will the problem stop reoccurring. There are some root causes of church harm, and we won’t solve them by excommunicating, shunning, or ignoring people who ask the Why questions. Successful companies pay large amounts of money for people to interrogate their systems and processes.

In my opinion, ignoring the people trying to get to the root cause of our issues is a big mistake, but churches do it all the time! Until we realize that people asking the hard questions are the “good guys,” we will continue to develop organizations that harm people and subsequently dismiss the very one that might have saved us.

 Be where you are, 

Be who you are, 

Be at peace,

Karl Forehand  

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About Karl Forehand
Karl Forehand is a former pastor, podcaster, and award-winning author. His books include Out into the Desert, Leaning Forward,  Apparent Faith: What Fatherhood Taught Me About the Father’s Heart, The Tea Shop and Being: A Journey Toward Presence and Authenticity.  He is the creator of The Desert Sanctuary podcast and community.  He is married to his wife Laura of 35 years and has one dog named Winston.  His three children are grown and are beginning to multiply! You can read more about the author here.

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