5 Whys - The Path to Resolution

Simplified presentation on post mortem analysis using 5 whys technique

Transcript

1. 5 WHYS THE PATH TO RESOLUTION
2. CAUSE AND EFFECT
3. $H!T HAPPENS •  Soluto 62 hours outage http://blog.soluto.com/2013/01/an-apology-from-the- soluto-team •  Adobe accounts hacked data exposed for 3M customers http://www.theverge.com/2013/10/3/4800042/adobe-suffers-cyber-attack- millions-of-customers-affected •  Knight 450M$ loss because of a bad rollout http://dealbook.nytimes.com/2012/08/02/trying-to-be-nimble-knight- capital-stumbles •  Plenty of more …
4. REACTION #1 THROW IT ON SOMEONE ELSE Sentences •  “This is your fault” •  “You shouldn’t have done this” Feelings •  Anger •  Shame •  Ego
5. 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
6. TEAM ADVANCEMENT Fail Understand Learn Adapt Change
7. SO WHAT’S 5 WHYS ANYWAY? When a problem occurs ask 5 times why? Simple as that.
8. 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
9. HISTORY Sakichi Toyoda 1867-1930 Japanese industrial revolution Toyota founder Toyota production system 1948-1975 Lean manufacturing, Kaizen and more
10. WHAT CAN GO WRONG
11. SYMPTOMS? Stop at symptoms Proceed asking why until you reach root cause.
12. SUPPORT Lack of support to ask the right "why" questions. Bring relevant people to have the support
13. KNOWLEDGE Find root causes that you already know Bring perspective from someone from outside the situation
14. PERSPECTIVE Different people come up with different causes Use small group. Which root cause fix will have the most impact
15. SINGULAR A single root cause where several root causes hide Don’t care about root causes Which improvement will eliminate broadest class of problems?
16. APPROACH
17. MORAL Search for guilty persons to accuse Use authority to give punishment
18. 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
19. HUMOR Worse bad things 450M$ bug... Or this
20. LAYOUT 15 minutes 3-4 people
21. FLOW 1.  Neutralizing statement 2.  Describe what happened 3.  5Ys 4.  Action items 5.  Document the resolutions 6.  Publish resolution to all relevant people
22. RESOLUTION
23. SHORT TERM Keep the problem from not recurring This is what we do right away LONG TERM Resources Prevention Not immediate Proportional investment
24. TEAM ADVANCEMENT Fail Understand Learn Adapt Change
25. 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