Asking the Five Whys in King County

A few months ago, folks at King County Solid Waste Division noticed a troubling trend in transfer station inspection reporting.

Every week, each of the 10 solid waste transfer stations must be inspected. These inspections are important. Failure to report inspections to safety officials could cause stations to be shut down. Stations also rely on the inspections to identify items that need repair.

Compliance needs to be 100%.

But only 65% of inspections were being reported on time.

Kerwin Pyle, a supervisor with Solid Waste Division, asked “Why?”

The first thing he learned was that the inspections were being done. They just weren’t being reported on time.

Pyle asked “Why?”

To start with, transfer station operators were faxing the report to their team leads (instead of directly to the Safety Officer) so that the leads could review the report, which caused a delay.

Pyle asked “Why?” again.

If there is work to be done, the team lead needs to arrange for a work order to be created and write that work order number on the form before sending it to the Safety Officer.


The Lead arranges for work to be done; the Safety Officer needs to know the work is arranged.


When Pyle asked the Safety Officer about this….Answer: No! The Safety Officer doesn’t need to have the work order number. The Safety Officer only needs the completed inspection report.


Of course, it is important to fix any problems identified during reviews, so a work order has to be completed. But it wasn’t necessary to fix those problems or to have a work order in order to process the inspection review itself.

Reporting the inspection and fixing the problem were two separate processes that had been mixed into a cocktail, causing unnecessary delays.

This is how the cocktailed processes used to look:

Pyle’s 5 Whys investigation has solved the problem, the two processes have been disentangled, and transfer stations are now complaint with their inspection reporting!

This is what the streamlined inspection reporting process looks like now:
Future State

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