An example of the process of “Why? Why? Why?” can be seen in the story of the Jefferson Memorial, part of the Juran Institute’s Quality Minutes Video Collection, and highlighted in Lee Perkin’s book Permission to Forget and Nine Other Root Causes of America’s Frustration with Education. It’s a story many of you may already know. The National Parks Service was having difficulty figuring out why the granite on the Jefferson Memorial was crumbling faster than its counterparts.  At first glance, the solution to the problem would seem to be removal of the birds – a process that could be both time consuming and inhumane. But delving deeper into the root cause made clear a simple, economical solution. Here is the process they went through to determine the root cause of the issue:

Problem: The granite of the Jefferson Memorial is crumbling at an increased rate

Why?

Because it is hosed off more frequently than other monuments

Why?

Because it needs to be cleaned more often

Why?

Because it has a larger bird population which leads to increased waste

Why?

Because there are large numbers of spiders for the birds to eat

Why?

Because there are large numbers of gnats for the spiders to eat

Why?

Because gnats are most active at dusk and are attracted to the lights of the Jefferson Memorial, which are turned on before dusk.

Solution: turn on the lights after dusk and the number of gnats will decrease, leading to a decrease in the number of spiders, then birds, and will eventually eliminate the need for frequent washings.

The solution appears through root cause analysis!