5 Whys - The Path to Resolution

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5 WHYS THE PATH TO RESOLUTION

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CAUSE AND EFFECT

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$H!T HAPPENS •  Soluto 62 hours outage http://blog.soluto.com/2013/01/an-apology-from-the- soluto-team •  Adobe accounts hacked data exposed for 3M customers http://www.theverge.com/2013/10/3/4800042/adobe-suffers-cyber-attack- millions-of-customers-affected •  Knight 450M$ loss because of a bad rollout http://dealbook.nytimes.com/2012/08/02/trying-to-be-nimble-knight- capital-stumbles •  Plenty of more …

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REACTION #1 THROW IT ON SOMEONE ELSE Sentences •  “This is your fault” •  “You shouldn’t have done this” Feelings •  Anger •  Shame •  Ego

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REACTION #2 TAKE THE BLAME Sentences •  “This is totally my fault” •  “I take full responsibility” •  “I promise it won’t happen again” Feelings •  Shame •  Remorse •  Humiliation

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TEAM ADVANCEMENT Fail Understand Learn Adapt Change

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SO WHAT’S 5 WHYS ANYWAY? When a problem occurs ask 5 times why? Simple as that.

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EXAMPLE •  A business partner is unhappy. •  Why? Because we didn't deliver on time •  Why? The job took much longer than we thought •  Why? We underestimated the complexity •  Why? We didn't list the individual stages needed •  Why? Because we were running behind on other stuff and did not give enough attention to time estimates

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HISTORY Sakichi Toyoda 1867-1930 Japanese industrial revolution Toyota founder Toyota production system 1948-1975 Lean manufacturing, Kaizen and more

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WHAT CAN GO WRONG

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SYMPTOMS? Stop at symptoms Proceed asking why until you reach root cause.

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SUPPORT Lack of support to ask the right "why" questions. Bring relevant people to have the support

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KNOWLEDGE Find root causes that you already know Bring perspective from someone from outside the situation

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PERSPECTIVE Different people come up with different causes Use small group. Which root cause fix will have the most impact

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SINGULAR A single root cause where several root causes hide Don’t care about root causes Which improvement will eliminate broadest class of problems?

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APPROACH

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MORAL Search for guilty persons to accuse Use authority to give punishment

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ECONOMIC How much does it cost (time, money) How much will it cost to fix Can we have a partial fix What do we risk in not fixing

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HUMOR Worse bad things 450M$ bug... Or this

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LAYOUT 15 minutes 3-4 people

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FLOW 1.  Neutralizing statement 2.  Describe what happened 3.  5Ys 4.  Action items 5.  Document the resolutions 6.  Publish resolution to all relevant people

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RESOLUTION

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SHORT TERM Keep the problem from not recurring This is what we do right away LONG TERM Resources Prevention Not immediate Proportional investment

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TEAM ADVANCEMENT Fail Understand Learn Adapt Change

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REFERENCES The Toyota Way 2001 http://www.slideshare.net/danmil30/how-to-run-a-5-whys- with-humans-not-robots http://www.reversim.com/2011/10/109-final-class-10.html