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Our Burning Platform and Using the 5 Whys to Think More Deeply about Corrective Action

by Christopher D. Chapman
July 23, 2020

Our Burning Platform and Using the 5 Whys to Think More Deeply about Corrective Action

by Christopher D. Chapman
July 23, 2020 | Comments (4)

The nation is at an inflection point. We are living amid a destabilizing Covid-19 pandemic, an unpredictable economic recession, and an explosion of racial dissent. Our ideal of an American democracy in which the supreme power of self-governance is invested in the People, inclusive of all races, genders, religions, abilities, and sexual orientations seems precarious and under attack--not unlike the black people ambushed by violence and systemic racism that Black Lives Matter protests. In times such as these, widespread feelings of dread, grief, misery, loss, and trepidation are understandable. We did not choose this crisis; it was cast upon us. A lean thinker would define this pivotal moment as a burning platform.

In Lean Lexicon, a burning platform emphasizes the need for immediate radical change due to urgent and dire circumstances. The term originates from a story about a man who suddenly finds himself standing on a fire ridden oil rig platform contemplating a life or death decision. Does he jump more than 100 feet into the freezing waters of the North Atlantic Ocean to escape being engulfed in flames, or does he reconcile himself to inevitable death by fire? If he is unable to face and quickly respond to his most ominous fear, he will remain paralyzed on the burning platform. And death is certain. However, if he is willing to take a literal leap of faith, no matter how probable his demise may seem, he may survive to see a brighter day.

In crises, your inner courage is awakened to answer the call. You choose whether to act on it or not. The person in the story decided to jump and was rescued by a boat shortly thereafter. The point is that it took a platform ablaze to cause this no-going-back attitude to arise. Now, we have reached such a crossroads in our country.

Note that the death-defying escape typically is told as the end of the story; I propose that it is just the beginning. Putting out the fire is not the end, either. Nor is returning to work afterward as if it is “business as usual,” pretending all is well. Imagine what comes next: The management and the surviving crew gather to remember their fallen co-workers, people who were like family. Picture them in your mind’s eye, weeping and mourning like the family members of George Floyd, Breonna Taylor, Michael Brown, Trayvon Martin, Ahmaud Arbery, and Eric Garner (unarmed Black human beings killed by fellow white human beings). After the funerals, scripture readings, video montages, and speeches, they reassemble and shift their attention back to the disaster. While it is painful to examine and “relive” the deadly incident, they realize there’s no benefit to scapegoating each other. Instead, they need to work together to identify the underlying causes to ensure that this does not happen again. Failure to take a systematic view of the problem will mean more lives lost unnecessarily in the future. No one wants that fatal outcome if we can help it. And we can avoid it if we are willing to learn from this moment and make changes in the best interest of everyone. Let’s examine this problem through a lean-thinking lens.

The 5 Whys: Identifying Root Cause

To do so, we will need to gather facts to help determine the root cause of the fire. You want to get to the bottom of this. It is crucial that you do. Lives are at stake. Superficial fixes won’t due. The investigation will require a deeper dive into the system; that is, how people work together as a whole team and their interconnecting activities on the oil rig. The lean thinking tool to make this more in-depth inquiry is called 5 Whys. Sakichi Toyoda, the founder of Toyota, developed the 5 Whys technique in the 1930s. It became popular in the 1970s. Toyota and lean thinkers around the world still use it to solve problems today. Taiichi Ohno, considered the father of the Toyota Production System (TPS), also known as the Thinking People System, made a practice of asking “why” five times in order to identify the root cause of the problem so that effective countermeasures could be developed and implemented. Paul O’Neill, former U.S. Treasury Secretary and CEO of Alcoa Inc., recommended “keep asking why like a third grader” until you grasp the situation and understand. Each answer to a single “why” forms the basis for the next “why” question. If the oil rig team asked why five times, this is what they would discover:


1. Why did the platform catch fire?

Gas was leaking from one of the condensate pipes

2. Why was gas leaking from one of the condensate pipes?

The pressure safety valve of an injection pump was removed during the day as part of routine maintenance and not replaced

3. Why was the pressure safety value of an injection pump removed during the day as part of routine maintenance and not replaced?

First shift maintenance did not communicate the incomplete repair to second shift

4. Why did first shift maintenance not communicate incomplete repair to the second shift?

No requirement for the status of maintenance repairs to be communicated at shift change

5. Why is the status of maintenance repairs not required to be communicated at shift change?

Management did not implement a standard communication policy/procedure for shift change (should also examine lock-out safety procedures to prevent operation of equipment being repaired)


Asking why five times is a rule of thumb. There’s nothing magical about the number five, however. In some instances, you may need to ask why a few more times, while in other cases, perhaps less. In the oil rig example above, the root cause is found in the answer to the fifth why. The corrective actions should address the answers to all five whys. Only addressing the first and second whys, by stopping the leak and replacing the pressure safety value, would not be sufficient. Lives would still be at risk. As you drill further down into the problem, you see daily practices and policies (or the lack thereof) that must be addressed to fully solve the problem. Likewise, when we search for solutions to the senseless murder of George Floyd (and police brutality), for example, firing a police officer or charging him with second-degree murder or banning a chokehold are essential, but they do not address the root cause. It’s deeper than that. More answers to more whys are necessary to uncover the root cause of this problem and other cases involving systemic racism. Systemic problems require deeper thinking and analysis to address the root cause.

Early in my professional career as a production supervisor many years ago, my mentor advised me to apply the 5 Whys to resolve quality problems between departments, and to ask why as many times as necessary until the final answer (root cause) resided resoundingly in my own hands. To him, the responsibility to see to the problem and implement the corrective actions rested on the shoulders of leaders. I agree. I certainly do not have all the answers, but like the oil rig workers, I know if all we are going to do is replace a pressure valve and return to business as usual without addressing the underlying practices and policies, then we have not done enough, and the problem will persist. Ibram X. Kendi, the author of How to be an Antiracist, also cautions us against this type of quick-fix, shallow thinking when addressing a systemic problem like racism. As he puts it, racial inequities emerge from racist policies. Racist policies are not created out of ignorance or hate, but rather, self-interest. Kendi suggests that trying to solve racism by “addressing ignorance and hate and expecting it to shrink is like treating a cancer patient’s symptoms and expecting the tumors to shrink. As long as the underlying causes remain, the tumors grow, the symptoms return, and inequities spread like cancer cells, and threaten the life of the body politic” (Kendi 2019). To eliminate the racial inequities in America, we must address the root cause; that is, the racist policies. We must become actively antiracist.

As we muster up the courage on our burning platform to face the centuries-old problem of systemic racism in our law enforcement, government, healthcare, education, housing, and employment, we know it will require deep analysis and asking “why” numerous times to get to the root cause of the problem. As lean thinkers, we should join with our diversity, equity, and inclusion experts to help transform our business cultures. We have a long-proven history of organizing cross-functional teams of employees in industries all around the world, soliciting and valuing their different perspectives, and harnessing their creativity and skills to solve what initially may have appeared to be insurmountable problems. As the saying goes, “We’re not new to this, we’re true to this!”

Like the man who stood on the burning platform, we must take a leap of faith despite the odds. Remaining stuck in the status quo is unacceptable. Our lives, our children’s lives, and their children’s lives are all at stake. While there is a long road ahead, I am inspired by Kendi’s words: “Once we lose hope, we are guaranteed to lose. But if we ignore the odds and fight to create an antiracist world, then we give humanity a chance to one day survive, a chance to live in communion, a chance to be forever free." Forward together! 


  1. Christopher D. Chapman, Lean in Lean Thinkers to Root Out Inequity, Lean Post, July 7, 2020
  2. Dan Markovitz, Why Good Lean Detectives Visit the Crime Scene, Lean Post, May 28, 2020
  3. The Late Paul O’Neill’s Playbook for Habitual Excellence, Lean Blog, April 21, 2020 
  4. 5 Whys: Getting to the Root of a Problem Quickly, Mindtools.com 
  5. The Burning Platform, Problem-Solving-Techniques.com, 2009-2015
  6. James P. Womack & Daniel T. Jones, Lean Thinking, Simon & Schuster Inc, 1996 
  7. Ibram X. Kendi, How to be an Antiracist, Penguin Random House LLC, 2019
Keywords:  reflection,  root cause
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4 Comments | Post a Comment
Mark Graban July 24, 2020
1 Person AGREES with this comment

Chris - Thank you for continuing to challenge our thinking. Thanks for your leadership here.

I look forward to more posts in your series.


Reply »


Thank you Mark. As we continue to build on the ideas presented in my articles, run experiments in the field, and learn more, we'll have more to share.  So, we appreciate your allyship and will keep the articles coming for the continuous improvement community. Our aim is to add value and inspire Lean thinkers to use their know-how to eliminate the waste of racism and create anti-racist organizations for the greater good. Forward together! 

Reply »

Bruce M July 24, 2020
2 People AGREE with this comment

Chris –

After reading and appreciating your willingness to challenge our thoughts & perspectives, I’d like to provide some more food for thought for us to ponder in the spirit of brotherly love so well stated by Robert Schuller:  “Love is my decision to make your problem my problem.”

It seems that all three inequities noted (ignorance, hate, and self-interest) may play a contextual part to one degree or another in racial as well as all other forms of discrimination.

It would seem upon closer examination however, that not having the right “Policies” in place may not be the final root cause. For while policies and laws do provide motivation to do the right thing, that motivation stems from an arbitrary external force, not internally from the heart.   

Asking another “Why” might generate a response something like:  Pride and a lack of respect for our fellow human beings.

Yet another “Why” might place us at the very beginning in the Garden where we humans were cursed with a flawed moral code because of our disobedience and rebellion toward the one to who we owe our very existence.  This same scenario is what we see manifested today; and have seen throughout history.  

We need to focus not so much on developing policies and laws (not denying their importance), that regretfully can be and are broken on an all too frequent basis, but on a higher moral code in the hearts & minds of all individuals.  One of humility, respect for one another, and gratitude for all that we have been given.

In the words of the Christian writer and apologist Ravi Zacharias: “The reason we have 17,000 pages in our law books is because we cannot follow 10 lines on a tablet made of stone”.

We in the Lean community might profit by continually reminding ourselves of another of Sakichi Toyoda’s contributions, the “5 Precepts”.  He espoused these from the beginning of Toyota Motor Company:

  1. Always be faithful to your duties, thereby contributing to the country and to the overall good.
  2. Always be studious and creative, striving to stay ahead of the times.
  3. Always be practical and avoid frivolousness.
  4. Always strive to build a homelike atmosphere at work that is warm & friendly.
  5. Always have respect for God and remember to be grateful at all times.


It is worthy to note that these are all spiritual admonitions, not a didactic list of do’s & don’ts.


Ultimately, let us all sit down, communicate, and reason with one another (Isaiah 1:18) out of a mutual respect and love for each other. Policies and laws then will reside somewhere upstream in Sakichi’s “5 Whys”.  They will be addressed from the heart and spirit with subsequent “Whys”.  It is an approach that will propel cascades of water on any burning platform effectively preventing having to make desperate decisions under dire circumstances.


Thanks again for your thought provoking post – “Forward together”!



Reply »


Thank you for sharing your comments. Framing love as a “decision to make your problem my problem” is a thought-provoking proposition. Racial inequities, the burning platform of our time, calls us all to see the problems of oppressed, marginalized, and brutalized people as OUR problems.  


While I am a Lean thinker, I do not claim to be an expert on race and discriminatory policies. I am confident, however, that policy matters (and I recognize that you also think that policy is important). Ibram X. Kendi, a leading scholar, states that racial disparities and inequity in America emerge from racist policies; and racial discrimination is an immediate and visible manifestation of an underlying racial policy.  5 Whys support his logic. As Kendi notes— we all have the power to discriminate, but only an exclusive few have the power to make policy.  He warns that focusing on racial discrimination takes our eyes off the central agents of racism: racist policy and policymakers.  His book, How to be an Antiracist is a great read to learn more.


In the biblical narrative, after Moses frees the enslaved Israelites, he returned to the holy mountain top and he is given the Ten Commandments, a summary of hundreds of laws found in the Old Testament. These directives are considered the basis of moral, spiritual, and ethical conduct- the age-old “Golden Rule.”  Sounds a lot like policies to me.


To the extent that policies reflect our values, antiracist policies may be seen as more than a list of do’s and don’ts, but rather as what author Gary Chapman defines as “affirming words,” in a workplace love language. Antiracist policies, then, might be a means of communicating with our beloved community in a world without poverty, racism, and war, as Dr. Martin L. King, Jr. envisioned.


Forward together, my brother.

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