5 whys - The Path to Resolution
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Effective post mortem analysis using the 5 whys technique What is it, How to do it right
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5 whys - The Path to Resolution
- 1. 5 WHYS THE PATH TO RESOLUTION
- 3. $H!T HAPPENS • Soluto 62 hours outage http://blog.soluto.com/2013/01/an-apology-from-thesoluto-team • Adobe accounts hacked data exposed for 3M customers http://www.theverge.com/2013/10/3/4800042/adobe-suffers-cyber-attackmillions-of-customers-affected • Knight 450M$ loss because of a bad rollout http://dealbook.nytimes.com/2012/08/02/trying-to-be-nimble-knightcapital-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
- 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
- 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
- 25. REFERENCES The Toyota Way 2001 http://www.slideshare.net/danmil30/how-to-run-a-5-whyswith-humans-not-robots http://www.reversim.com/2011/10/109-final-class-10.html