Jeff Bezos and Root Cause Analysis

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Review of: Root Cause Analysis
Business Methodology:
Pete Abilla

Reviewed by:
On January 23, 2009
Last modified:October 17, 2014


Jeff Bezos explains and demonstrates the 5 Whys and shows how quick and effective Root Cause Analysis can be done in an organization.

I’m always impressed when CEO’s demonstrate Deming-like behavior as they lead; it’s rare, but there’s almost a magical, mobilizing, and inspiring force that happens when CEO’s or corporate leaders behave in a respectful, inspiring, common-sense, and thoughtful way.

Today, I’m reminded of an experience back in 2004 while I worked for — something Jeff Bezos did that I still carry with me to this day.

Jeff Bezos Demonstrates 5 Whys

During Q4, Bezos and his leadership team have a tradition of visiting the Fulfillment Centers, spends time with the associates, and also physically works on the floor alongside everyone else.

During one visit, there had just been a safety incident where an associate had damaged his finger.  When Jeff learned of this during a meeting, he was very disturbed and got very emotional — angry at first, then felt very bad for this associate and his family.  Then, he did something remarkable.

He got up, walked to the whiteboard and began to ask the 5-why’s (I quote the below from memory):

Why did the associate damage his thumb?

Because his thumb got caught in the conveyor.

Why did his thumb get caught in the conveyor?

Because he was chasing his bag, which was on a running conveyor belt.

Why did he chase his bag?

Because he placed his bag on the conveyor, but it then turned-on by surprise

Why was his bag on the conveyor?

Because he used the conveyor as a table

So, the likely root cause of the associate’s damaged thumb is that he simply needed a table, there wasn’t one around, so he used a conveyor as a table.  To eliminate further safety incidences, we need to provide tables at the appropriate stations or provide portable, light tables for the associates to use and also update and a greater focus on safety training.  Also, look into preventative maintenance standard work.

Jeff Bezos on Lean and Lessons Learned

There are several things amazing about this experience:

  1. Jeff Bezos cared enough about an hourly associate and his family to spend time discussing his situation.
  2. Jeff properly facilitated the 5-why exercise to arrive at a root cause: he did not blame people or groups — no finger pointing.
  3. He involved a large group of stakeholders, demonstrated by example, and arrived at a root cause and he didn’t focus on symptoms of the problem.
  4. He is the founder and CEO of, yet he got involved in the dirt and sweat of his employees’ situation.
  5. In that simple moment, he taught all of us to focus on root causes — quickly — not heavily relying on data or overanalysis of the situation, and yet he was spot-on in identifying the root causes of the safety incident.

Every company has its warts and zits, but, make no mistake — Jeff Bezos is a Lean and Six Sigma fanatic and, in my opinion, makes a strong effort to run his company in a very Deming-like way.

How will you apply the 5-why’s today?  Will you focus on the root causes of your challenges and not just on the symptoms?


  1. Jedediah Smith says

    Only 5 whys? I can think of a few more:

    Why did the conveyor turn on “by surprise”?

    Why didn’t it have failsafes to deal with interfering bags or thumbs?

    Why didn’t this guy have the smarts/training to know that bags don’t go on conveyors?

    …or that you shouldn’t go chasing after them if the conveyor turns on?

    Getting at the root of problems is a great idea, but don’t think you can stop asking questions at magical number 5. That said, it’s still better than zero.

  2. says

    Great story. Wish he had taken a step further:

    Why was there no table??

    I bet SOMEBODY in the organization had that idea previously and maybe a supervisor said no. “It’s too expensive” or “we don’t have room” could have been likely excuses.

    I hope Bezos looked into more than just these tables — in what other cases were potential improvements like this overlooked or ignored?

    You need more people than the CEO thinking this way.

  3. says

    Interesting conversation on this article at ycombinator:

    27 points by SwellJoe 21 hours ago | link

    Bezos spoke at Startup School last year, and I think a lot of people were struck by how aware he was about very technical details at Amazon (Web Services, specifically). What impressed me most, however, was that when one of his employees gave a waffly non-answer to a question from the audience, he called him on it (subtly and politely), and made the guy commit to a real answer to the question…and made him personally responsible for it (with a comment along the lines of, “You can email him for that information and he’ll get it to you.”).

    It was interesting to see, and it struck me as one of the things about Bezos that can explain how he has been so successful with a “bookstore on the web” when so many other “X on the web” concepts failed. You can’t control every customer interaction in a company that size, but in that moment he established a precedent for that particular group of employees (probably folks who don’t deal with customers a lot, since they were tech folks from AWS).

    What I’m saying is that Bezos has certainly drunk some kind of obsessively customer-focused Kool-Aid, and I think I would take any opportunity I could to learn from him.


    18 points by gruseom 18 hours ago | link

    That’s interesting. The thing that stuck with me from that talk was when he was asked about Google App Engine. His answer was that Amazon has had a policy for years of not talking about competitors, not because they want to be evasive but because they don’t want to take their focus off customers. Attention paid to what competitors are doing is attention not paid to what customers need next. I was deeply impressed by that.


    7 points by bprater 20 hours ago | link

    There are many parallels between Bezos and Jobs. Like you mentioned, Bezos is great at both macro- and micro-perspectives of his business.

    Amazon didn’t win because they were one of the first out of the gate, it’s because Bezos has been obsessive (like Jobs) about the quality of his product.


    5 points by jodrellblank 16 hours ago | link

    That’s only four why’s, and it doesn’t address why the employee suddenly needed a table.

    Which means it may not be the “root cause”, either, and the offered “more tables” solution may not help.


    2 points by jerf 15 hours ago | link

    I don’t think there’s anything particularly magical about the number five. We weren’t there and that may have been adequately deep analysis; we don’t have the information to tell.

    Personally, I can’t say I’m inclined to think “the employee needs a table” is likely to have any useful root cause that goes any deeper… “I need a table” is hardly some sort of exotic need.


    2 points by mattmcknight 14 hours ago | link

    The whole episode is recounted from memory, not a transcript, so it’s probably off a little. The real why answer is ‘because he didn’t have anywhere else to place objects in the work area’. The table is one solution. You could go another layer deep and wonder why the work area was designed without a stable horizontal work surface. Maybe the job duties changed, maybe the designers didn’t know. At the fundamental level though, you’ve discovered a good corrective action.


    1 point by fauigerzigerk 7 hours ago | link

    I suspect that there is a long tail of root causes when it comes to accidents. So a little more analysis of a number of cases might have led to a better conclusion.


    1 point by extension 9 hours ago | link

    I commented about this on the linked site and it was deleted.

    Adding a table strikes me distinctly as ignoring the root of the problem, which probably has more to do with safety standards and training. There has to be a more robust way to prevent accidents than luring people away from them.

    So, ironically, this seems to be an example of asking too many questions, and we’re not even at 5 yet.


    2 points by akd 8 hours ago | link

    The “5 whys” don’t need to be exactly 5; it’s just the name for the process of getting to the root cause of a problem.


    1 point by potatolicious 2 hours ago | link

    Actually, “luring” people away from accidents is often a better way than strict training. “Don’t jay-walk across the freeway” will only work when a viable (and safe) crossing is close by. Otherwise your users will simply ignore your training to make their lives easier.


    5 points by kcy 20 hours ago | link

    Great talk by Bezos on how the internet is more like electricity than the gold rush:

    3 points by tholder 19 hours ago | link

    Seems like Jeff could do with getting down to the distribution floor again!


    1 point by gruseom 16 hours ago | link

    I hadn’t seen that. Amazon is a puzzle to me. They do so many things right, yet I keep hearing that it is not a good place to work.


    3 points by byrneseyeview 14 hours ago | link

    Probably because they do the software stuff right, but a huge number of their employees are schlepping boxes in warehouses, or doing customer service?

    Anyway, it’s not an especially big deal to me that they would fire someone for taking too many sick days right before Christmas. If they disclose this to employees beforehand, they’re likely to weed out people who tend to take sick days, whether for legitimate reasons or not.


    1 point by gruseom 10 hours ago | link

    I’ve also heard from software people that it isn’t a good place to work. In fact, I’ve only heard it from software people. I haven’t talked to or read blog posts from anyone who’s worked in their warehouses.


    1 point by potatolicious 2 hours ago | link

    Depends on where you are. “Front-facing” teams (e.g. site front-end and whatnot) tend to have a lot of sleepless nights when things blow up and a fix is immediately needed.

    Software guys in the “back” tend to not live such a stressful existence, since there’s far more time leeway for fixing things.


    1 point by ChaitanyaSai 20 hours ago | link

    Kind of off-topic, but does Yahoo (or is it the publisher?) really think that interjecting ads in the middle of a narrative actually makes people want to click on the link? Do they really not know the least about human psychology? Most people who get to that point in the article have an inertial interest in finishing, and also a bias towards skimming over any contextual discontinuity. There are contrast effects that pull you towards them, and those that are obstacles people are happy to ignore. This is the second kind.

    And, I should add, what works on television (ads in the middle) doesn’t work in the same way for text. There is a natural ebb and flow of attention in a TV narrative,


    1 point by h34t 3 hours ago | link

    I would guess they pay more attention to what works and what doesn’t than to psychological theory or conjecture. It’s easy for anyone to monitor what kind of ads perform better than others, and since ads are much of Yahoo’s bread and butter, you can be sure they are paying attention.

  4. says


    Thank you for stopping by to read this article.

    Lean Thinking is not about putting blame on people, as is the focus of your question “Why didn’t this guy have the smarts/training to know that bags don’t go on conveyors?”. Also, asking 5 questions is just the name for the approach, but one could get to the root cause at 5 or 50 – it depends.

    The point here is this: the CEO of a multi-billion dollar company taught his employees by example how to attack our challenges by getting closer to the root cause and implementing countermeasures that don’t just address symptoms.

    @Graban – yes, Jeff Bezos could have gone much further. Regardless, he taught effectively and gave others the courage to overcome the typical management excuses for not doing the right thing. Those countermeasures were already suggested, I’m sure, but the associates were probably not listened to. Despite that, his example gave others the courage to approach things differently next time.

  5. says

    discussion on y.combinator:

    2 points by michaelbuckbee 13 minutes ago | link

    Here’s an interesting example of the insights and changes he’s made as a result his time spent at the fulfillment centers.


    12 points by dbul 10 hours ago | link

    Yes! This is what more CEOs of large companies need to do. If you are a CEO, you need to understand what is going on in the company first hand, not by playing whisper down the lane with the chain of command. (This is my philosophy, hopefully reality one day.)


    16 points by staunch 9 hours ago | link

    He’s going to get a very sanitized version of the experience. What would be really amazing is if he disguised himself and went to work in the warehouse unannounced. Although I’m sure there would be plenty of self righteous outrage if he actually did.


    9 points by utefan001 4 hours ago | link

    I am biased, but David Neeleman (JetBlue, now starting Azul) is an amazing CEO. Just a few days ago he was flying around Brazil on his new Azul airline anonymously to verify his employees are implementing the level of customer service he is hoping for.

    Edit: Compare that to the Washington DC Metro Board of Directors who don’t even ride the Metro Trains they are overpaid to “direct”.


    15 points by dbul 9 hours ago | link

    The important thing is that he is going to be at the same level as those employees. He can ask them questions such as, “What needs improvement?” He’s a bright guy so I would imagine he can figure out a way to make the employees feel comfortable enough to be dead honest with him. While you are right that there will be some cleansing, in general the employees can show him what they are talking about in a way that some feedback form just couldn’t accomplish. (I must note that even dishing out a feedback form to employees once or twice a year is a giant step for many companies.)


    1 point by jeroen 6 minutes ago | link

    A week might be long enough for the employees to get used to his presence and fall back to their normal behaviour.

    I also expect Bezos to have thought of that and of the alternatives and to have made an informed decision.


    3 points by wolfish 2 hours ago | link

    I think this is a pretty interesting gesture. It is possible that Mr. Bezos will learn something that will help him improve working conditions and efficiency within the company. But who will be the CEO while he is busy working in the distribution center? It seems like an inefficient use of his time. Does this show a lack of faith in lower management?


    3 points by jbarciauskas 1 hour ago | link

    A good CEO should be able to delegate day to day activities for a week – how else would he ever get to go on vacation? In fact, a good CEO should probably be able to delegate all day to day activities he might be involved in, in case of an emergency, in case he’s hit by a bus, or just so he can spend a day thinking strategically.


    1 point by wolfish 1 hour ago | link

    Good point. I guess the question is: in the long run will Amazon be better of having Jeff Bezos performing his usual duties as CEO 3/23-3/27 or acquiring first hand the experience of working in a distribution center. The net difference is probably de minimis. Although it does make for good publicity and employee moral. So net-net I think this is a decent one-off gesture, but I don’t think it belongs in every CEO’s playbook.


    2 points by easyfrag 1 hour ago | link

    I attended a talk by a consultant on how they do these “best places to work” surveys. Setting aside the issue of how accurate these surveys are, one of the dominant traits of these organizations is that performance appraisals float up the chain of command as well as down.

    This means that employees and junior managers get a chance to evaluate their bosses as much as the bosses evaluate them. I don’t think Bezo’s action shows a lack a faith in lower management but rather a “trust but verify” approach.

    Of course it might be a more strategic approach to finding out how stuff really works on the front line. Given a big enough management structure the “on the floor” reality might not filter up to the board room correctly. Remember the game of gossip? That effect plagues large organizations.


    2 points by hhm 1 hour ago | link

    I don’t think this is a gesture. He’s learning about the company and about how to improve it.


    2 points by wolfish 2 hours ago | link

    Instead of downvoting, why not post why you disagree? I think this is a valid line of inquiry.


    8 points by catone 10 hours ago | link

    Admirable, certainly. It’s nice to see a CEO who is keen to experience his business from every angle.

    From observing the workplace of my girlfriend, who has recently worked in retail for a large, national corporation, I can tell that the particular company she works for definitely doesn’t. Very often they get instructions about how to rearrange the sales floor that anyone actually working there with the customers would never in a million years think was a good idea — usually, a few weeks later, they’re told to change back to what they were doing. My guess is that’s how it goes in most big companies. Eventually, the suits don’t touch the nitty gritty parts of the business, and they end up getting way out of touch.

    That said, I doubt if Bezos, by virtue of the fact that everyone will know who he is, will run into the rumored “sweatshop” conditions at some Amazon distro centers (if those rumors are at all true, which is impossible for anyone who hasn’t worked in one to say):

    EDIT: Also, does Jeff Bezos have a blog? His is one I would really love to read.


    6 points by brandonkm 10 hours ago | link

    From the stories I’ve read over the years on Jeff Bezos, this is perfectly in line with his management style and persona. If it was anyone else I would probably questions motives a bit more, but this seems to simply be wanting to experience the work and environment on the ground level. Its gaining valuable perspective that helps effective CEOs run their companies better.


    2 points by fortes 2 hours ago | link

    All managers at Amazon above a certain level are required to work in a fulfillment center once a year.


    3 points by redhex 7 hours ago | link

    Now, I am wondering how will those IT guys at Amazon can do a A/B test of how effective this move by Jeff Bezos will be.


    3 points by sketerpot 11 hours ago | link

    I was expecting to hear what he learned from the experience.


    4 points by Zev 10 hours ago | link

    The week isn’t over yet.


    1 point by goodgoblin 1 hour ago | link

    I was wondering where Jeffy-B had gone to. I stopped getting personal emails from him a while back and I had started to get worried.

  6. Christian Beck says

    Hi Pete,
    this is a very nice story. I am just reading the book from Steve Denning about Storytelling and from what I learned there, I think there’s only one thing missing in your story to make it perfect: The happy end. If this story (which is a springboard story in Dennings terminology) is designed to trigger change, the audience needs the happy end so that they can see it as an example for how 5Whys really had an impact. So: Do you know if they really changed somethin in the process in the Fulfillment center afterwards?
    Christian Beck

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