5 whys - The Path to Resolution
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5 whys - The Path to Resolution

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Effective post mortem analysis using the 5 whys technique

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 5 whys - The Path to Resolution Presentation Transcript

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