Why made, why missed poster

A defect that reaches a customer got through twice: once when it was made, and again when the checks that should have caught it did not. Many teams fix only the first. This poster splits the analysis into three legs: why we made it (the occurrence cause), why we missed it (the escape, or non-detection, cause) and why our system allowed it (the planning cause in the FMEA, control plan or standards). Each leg gets its own 5 whys and its own fix.

Download the poster

The PNG is free to download now. The print-ready vector PDFs open after a short form, once.

Download PNG (300 dpi)2550 x 3300 px, prints at 8.5 x 11 in · 452 KB · no form

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The words on the poster

Why made, why missed

A defect that reached the customer got through twice. Find both causes, then the system gap.

Made Why did we make it? Start where the defect was made. 5 whys down to a process cause. Fix: stop it being made.
Missed Why didn't we catch it? Which check should have found it? Why did that check miss it? Fix: detect it at the source.
System Why did our system allow it? Was the risk in the FMEA and control plan? If not, why not? Fix: update them and the standards.

Fix one leg only and the same defect can still be made, still be missed, or turn up on the next product.

On the floor

How to use it

Putting the Why made, why missed poster to work

1
Use it on every customer complaint and every defect found after final inspection.
2
Run a separate 5 whys for each leg and write all three on the 8D or A3.
3
Check the escape leg names the check that should have caught the defect.
4
Pair it with the free 8D report template and PFMEA template.

Where the poster goes and how to teach with it, in the order to try them.

Which size to print

24 x 36 in or A2: a main wall or team board, read from a few metres away.
18 x 24 in or A3: a station or notice board. The A3 file also fits 11 x 17 in paper.
Letter or A4: a clipboard, binder or handout, on any office printer.

Every PDF is vector, so it stays sharp at full size. Nothing runs to the edge of the page, so no bleed is needed.

Sources and notes

Ford's 8D (team oriented problem solving) separates the root cause from the escape point, the earliest place in the process where the problem should have been detected.