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Root Cause Analysis
David Hanson
dphanson63@yahoo.com
https://www.linkedin.com/in/david-hanson/
https://www.slideshare.net/DavidHanson5
March 2023 David Hanson | ANE
2
Introduction
Too often root cause analysis of a development or support issue is skipped in our rush
to recover.
Often the actions taken address symptoms of the problem, but not the root cause.
This presentation reviews two popular approaches for root cause analysis.
David Hanson | ANE
3
Use this method to find the deeper root cause
Keep asking why until you can blame
management!
5 Whys Fishbone
Use this method to find multiple root causes
Also known as Ishikawa, when diagrammed
resembles a set of fishbones
Two Most Popular Techniques
Can be used together too…
David Hanson | ANE
Why?
Why?
Why?
Why?
Why?
4
1) Why did the issue occur?
2) Why did a process not run?
3) Why was the schedule not set when
deployed?
4) Why are we shortcutting our deployment
process?
5) Why aren’t releases systematic and
automated?
Why? Because!
1) Because a process did not run.
2) Because schedule was not set during
deployment.
3) Because worked alone, without checklist,
without validation.
4) Because releases happening ad hoc and on
demand.
5) Because management has been rushing us.
Why? Because!
What are the corrective actions that you might propose?
David Hanson | ANE
5
Manpower
Method
Machine
Materials
Measurement
Environment
Management
Money
People
Process
Program
Product
Policy
Place
Promotion
Price
Suppliers
Skills
Surroundings
Systems
Ms Ps Ss
Popular alternative where each M
loosely maps to a P
Preferred for “Services”
Environment often listed as Mother
nature or Milieu
Popular Fishbone Categories
Adjust categories to what makes sense for your work.
David Hanson | ANE
6
Definition: prevents occurrence
What are some examples of preventive action?
Preventive Action Corrective Action
Definition: prevents recurrence
What are some examples of corrective action?
Preventive or Corrective Action
David Hanson | ANE
7
Monitoring dashboards for
successful data refresh every
Monday morning:
preventive action, corrective action,
or something else?
A current practice for my current team…
David Hanson | ANE
8
If the action taken results in manual or automated
support or periodic maintenance, then the action
arguably does not prevent occurrence or
recurrence
Symptom Cause
When possible, better to find and address the
root cause rather than treating the symptom
Support and Maintenance
David Hanson | ANE
Acetaminophen Amoxicillin
9
Analysis of issue might conclude
works as designed
Root cause analysis might lead to
need for user or support team
education
Analysis of issue might identify
defect
Defects might be addressed now,
soon, or later depending on
workarounds and impact
Analysis of issue might identify
missed, new, or changed
requirement
Enhancements generally written
as user stories for future sprints
Not issue Defect Enhancement
If defects frequent, then process
needs inspection more than code
Is sprint review with stakeholders
generating enhancement requests?
Still worth root cause analysis with
preventive or corrective actions
Support Issue Triage
David Hanson | ANE
10
Classification Support Action
Critical No workaround or
control available
Add to top of sprint backlog and
address ASAP by swarming
Major Complex workaround
or control
Add to sprint backlog and address
in current sprint
Minor Simple workaround
or control
Add to product backlog and
address in future sprint
Trivial Workaround or
control not required
Add to product backlog or
incorporate into existing story to
address when convenient
Severity of impact and frequency
of occurrence are often
considered in addition to whether
workaround or control exists
A Starting Point for Defect Classification
David Hanson | ANE
11
Understand how to recognize the
symptom and implement the
recovery
Implement the recovery and
understand the root cause or
causes
Implement the recovery and then
take corrective action to address
root cause
First Time Second Time Third Time
If impact modest and recovery simple might consider
frequency of issue, instead of count
For high impact issues with complex recovery might want to
take corrective action earlier
My Approach for Support Issues
David Hanson | ANE
12
If leveraging 5 whys, address first
level root cause
If leveraging fishbone, address
most impactful* root cause
If leveraging 5 whys, address
second level root cause
If leveraging fishbone, address
second most impactful root cause
If leveraging 5 whys, address nth
level root cause
If leveraging fishbone, address nth
most impactful root cause
1st Time 2nd Time nth Time
Pareto Principle (extrapolated):
40% effort yields 96% value
*Pareto Principle:
20% effort yields 80% value
Other approaches for addressing root causes
If keeps repeating, then keep addressing next root cause. Over time system should become very robust and frequency of related issue increasingly rare.
David Hanson | ANE
…
13
1) Why?
2) Why?
3) Why?
4) Why?
5) Why?
Why? Because.
1) Because.
2) Because.
3) Because.
4) Because.
5) Because.
Who has a relatively simple issue that wants to try 5 whys?
David Hanson | ANE
14
• Cause • Cause • Cause
M or P M or P M or P
Who has a relatively complex issue that wants to try
fishbone?
David Hanson | ANE
• Cause • Cause • Cause
M or P M or P M or P
Symptom
15
Agile Problems
1. Why is Scrum simple to understand but difficult to master?
2. Why is cycle time for release of valuable software routinely measured in months and
not weeks?
3. Why is the product owner routinely over utilized and the Scrum master routinely
under utilized?
4. Why do some team members have too much to do and other team members have
too little to do?
5. Why are so many user stories written as developer tasks with acceptance criteria
written as task lists?
These questions likely have multiple sources for root cause and lend themselves to fishbone technique.
David Hanson | ANE
16
• Cause • Cause • Cause
M or P M or P M or P
Root cause analysis for a troublesome Agile problem?
David Hanson | ANE
• Cause • Cause • Cause
M or P M or P M or P
Agile Problem?
17
When?
After recurring support issue
After escaped defect
After system outage
For unstable velocity
For long cycle times
After a failed sprint
When team morale low
When improvements stalled
When transformation stalled
Where?
Retrospectives
Post-mortems
Lessons Learned
Incident Reviews
When and Where
David Hanson | ANE
18
Reflection
So, what was most useful for you here?
What was missing or what would you like to see next?
David Hanson | ANE
Appendix
Related Concepts
Lean Toolkit
20
Has a similar aspect to 5 Why’s, except questions
whether the problem is worth tackling, and if so,
considering at least the first step in resolution.
What, So What, Now What Mind Mapping
Has a similar aspect to Fishbone, except this
brainstorming approach is usually used to
discover a range of interesting problems or
creative solutions.
Related Concepts
David Hanson | ANE
21
More Tools in the Lean Toolkit
Not to be overlooked 5 Whys and Fishbone covered in depth in this presentation
Lean Canvas
Single page project definitions
useful to quickly assess and
prioritize projects
A3 Problem Solving
Single 11x17 sheet useful for
tracking problem from current
state to future state to solution
Value Stream Mapping
Map steps from idea to use,
noting value add, non-value but
required, and non-value add
Voice of Customer
Ask who, what, why, when and
where to gather the voice of
your customer
Gemba Walk
Go-and-see, observing business
processes and software
development first-hand
SIPOC
Process flow technique
following supplier > input >
process > output > customer
5S
Organize work and workplace
using sort, straighten, shine,
standardize, sustain
David Hanson | ANE
A3
A
4
A
4
Who
What
Why
When
Where
S I P O C
S
S
S
S
S
Lean Waste
Checklist for identifying types
of waste which can then be
eliminated or minimized
5
• Defects
D
• Overdone
O
• Wait
W
• Neglect
N
•Transport
T
•Inventory
I
•Motion
M
•Excess
E
Non-
value
Required
Value
David Hanson
dphanson63@yahoo.com
https://www.linkedin.com/in/david-hanson/
https://www.slideshare.net/DavidHanson5

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Root Cause Analysis

  • 1. Root Cause Analysis David Hanson dphanson63@yahoo.com https://www.linkedin.com/in/david-hanson/ https://www.slideshare.net/DavidHanson5 March 2023 David Hanson | ANE
  • 2. 2 Introduction Too often root cause analysis of a development or support issue is skipped in our rush to recover. Often the actions taken address symptoms of the problem, but not the root cause. This presentation reviews two popular approaches for root cause analysis. David Hanson | ANE
  • 3. 3 Use this method to find the deeper root cause Keep asking why until you can blame management! 5 Whys Fishbone Use this method to find multiple root causes Also known as Ishikawa, when diagrammed resembles a set of fishbones Two Most Popular Techniques Can be used together too… David Hanson | ANE Why? Why? Why? Why? Why?
  • 4. 4 1) Why did the issue occur? 2) Why did a process not run? 3) Why was the schedule not set when deployed? 4) Why are we shortcutting our deployment process? 5) Why aren’t releases systematic and automated? Why? Because! 1) Because a process did not run. 2) Because schedule was not set during deployment. 3) Because worked alone, without checklist, without validation. 4) Because releases happening ad hoc and on demand. 5) Because management has been rushing us. Why? Because! What are the corrective actions that you might propose? David Hanson | ANE
  • 5. 5 Manpower Method Machine Materials Measurement Environment Management Money People Process Program Product Policy Place Promotion Price Suppliers Skills Surroundings Systems Ms Ps Ss Popular alternative where each M loosely maps to a P Preferred for “Services” Environment often listed as Mother nature or Milieu Popular Fishbone Categories Adjust categories to what makes sense for your work. David Hanson | ANE
  • 6. 6 Definition: prevents occurrence What are some examples of preventive action? Preventive Action Corrective Action Definition: prevents recurrence What are some examples of corrective action? Preventive or Corrective Action David Hanson | ANE
  • 7. 7 Monitoring dashboards for successful data refresh every Monday morning: preventive action, corrective action, or something else? A current practice for my current team… David Hanson | ANE
  • 8. 8 If the action taken results in manual or automated support or periodic maintenance, then the action arguably does not prevent occurrence or recurrence Symptom Cause When possible, better to find and address the root cause rather than treating the symptom Support and Maintenance David Hanson | ANE Acetaminophen Amoxicillin
  • 9. 9 Analysis of issue might conclude works as designed Root cause analysis might lead to need for user or support team education Analysis of issue might identify defect Defects might be addressed now, soon, or later depending on workarounds and impact Analysis of issue might identify missed, new, or changed requirement Enhancements generally written as user stories for future sprints Not issue Defect Enhancement If defects frequent, then process needs inspection more than code Is sprint review with stakeholders generating enhancement requests? Still worth root cause analysis with preventive or corrective actions Support Issue Triage David Hanson | ANE
  • 10. 10 Classification Support Action Critical No workaround or control available Add to top of sprint backlog and address ASAP by swarming Major Complex workaround or control Add to sprint backlog and address in current sprint Minor Simple workaround or control Add to product backlog and address in future sprint Trivial Workaround or control not required Add to product backlog or incorporate into existing story to address when convenient Severity of impact and frequency of occurrence are often considered in addition to whether workaround or control exists A Starting Point for Defect Classification David Hanson | ANE
  • 11. 11 Understand how to recognize the symptom and implement the recovery Implement the recovery and understand the root cause or causes Implement the recovery and then take corrective action to address root cause First Time Second Time Third Time If impact modest and recovery simple might consider frequency of issue, instead of count For high impact issues with complex recovery might want to take corrective action earlier My Approach for Support Issues David Hanson | ANE
  • 12. 12 If leveraging 5 whys, address first level root cause If leveraging fishbone, address most impactful* root cause If leveraging 5 whys, address second level root cause If leveraging fishbone, address second most impactful root cause If leveraging 5 whys, address nth level root cause If leveraging fishbone, address nth most impactful root cause 1st Time 2nd Time nth Time Pareto Principle (extrapolated): 40% effort yields 96% value *Pareto Principle: 20% effort yields 80% value Other approaches for addressing root causes If keeps repeating, then keep addressing next root cause. Over time system should become very robust and frequency of related issue increasingly rare. David Hanson | ANE …
  • 13. 13 1) Why? 2) Why? 3) Why? 4) Why? 5) Why? Why? Because. 1) Because. 2) Because. 3) Because. 4) Because. 5) Because. Who has a relatively simple issue that wants to try 5 whys? David Hanson | ANE
  • 14. 14 • Cause • Cause • Cause M or P M or P M or P Who has a relatively complex issue that wants to try fishbone? David Hanson | ANE • Cause • Cause • Cause M or P M or P M or P Symptom
  • 15. 15 Agile Problems 1. Why is Scrum simple to understand but difficult to master? 2. Why is cycle time for release of valuable software routinely measured in months and not weeks? 3. Why is the product owner routinely over utilized and the Scrum master routinely under utilized? 4. Why do some team members have too much to do and other team members have too little to do? 5. Why are so many user stories written as developer tasks with acceptance criteria written as task lists? These questions likely have multiple sources for root cause and lend themselves to fishbone technique. David Hanson | ANE
  • 16. 16 • Cause • Cause • Cause M or P M or P M or P Root cause analysis for a troublesome Agile problem? David Hanson | ANE • Cause • Cause • Cause M or P M or P M or P Agile Problem?
  • 17. 17 When? After recurring support issue After escaped defect After system outage For unstable velocity For long cycle times After a failed sprint When team morale low When improvements stalled When transformation stalled Where? Retrospectives Post-mortems Lessons Learned Incident Reviews When and Where David Hanson | ANE
  • 18. 18 Reflection So, what was most useful for you here? What was missing or what would you like to see next? David Hanson | ANE
  • 20. 20 Has a similar aspect to 5 Why’s, except questions whether the problem is worth tackling, and if so, considering at least the first step in resolution. What, So What, Now What Mind Mapping Has a similar aspect to Fishbone, except this brainstorming approach is usually used to discover a range of interesting problems or creative solutions. Related Concepts David Hanson | ANE
  • 21. 21 More Tools in the Lean Toolkit Not to be overlooked 5 Whys and Fishbone covered in depth in this presentation Lean Canvas Single page project definitions useful to quickly assess and prioritize projects A3 Problem Solving Single 11x17 sheet useful for tracking problem from current state to future state to solution Value Stream Mapping Map steps from idea to use, noting value add, non-value but required, and non-value add Voice of Customer Ask who, what, why, when and where to gather the voice of your customer Gemba Walk Go-and-see, observing business processes and software development first-hand SIPOC Process flow technique following supplier > input > process > output > customer 5S Organize work and workplace using sort, straighten, shine, standardize, sustain David Hanson | ANE A3 A 4 A 4 Who What Why When Where S I P O C S S S S S Lean Waste Checklist for identifying types of waste which can then be eliminated or minimized 5 • Defects D • Overdone O • Wait W • Neglect N •Transport T •Inventory I •Motion M •Excess E Non- value Required Value

Editor's Notes

  1. Fishbone also known as Ishikawa Fishbone diagram modified Original by Kathy Wu from Noun Project
  2. Sometimes recommendation is to keep asking why until you can blame management. Leveraging empathy, you might consider why management is doing what they are doing. Why is management rushing us? What happens when you fix on the first? Second? Third? Fourth?
  3. Measurement | Policy Machine | Program Manpower | People Environment | Place Materials | Product Method | Process
  4. Failure Mode Analysis Reliability Analysis Pre-mortem
  5. https://thenounproject.com/term/business-model-canvas/116286/ https://www.drcone.com/2017/12/02/3925/ Replace 5 Whys and Fishbone with visuals for Value Stream Mapping and Lean Waste