Root Cause Analysis: Fact and Fiction
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In this presentation I discuss how poor implementations of root cause analysis undermine an organization’s attempts to enable a learning culture. Audience members will: 1. understand the intent of root cause analysis; 2. be able to recognize its limitations; 3. fix their implementations.
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Root Cause Analysis: Fact and Fiction
- 1. Root Cause Analysis Fact and Fiction Dustin Collins @dustinmm80 CyberArk Conjur
- 2. Origins of Root Cause Analysis - First implemented in 1958 in Toyota manufacturing plants (5 Whys) - Has since been adopted and tailored to many other industries
- 3. Why do RCA? To better understand the underlying causes of problems so we can address them and prevent them happening again.
- 4. When to do RCA? - When issues happen more than once - When an outage affects many users - When a system is not functioning as designed
- 5. 5 Whys - Start with a problem statement - Ask why - Repeat until root cause is found
- 6. Issues with 5 Whys Incorrect or leading problem statement can point to the wrong issue. Not very useful in complex situations, where you can’t answer why in the moment.
- 7. Issues with 5 Whys It’s not repeatable - Different people may get different results - Same people at a different time may get different results
- 8. Issues with 5 Whys Linear thinking leads teams to drive towards one root cause. There is usually more than one root cause. Human error is not a valid root cause.
- 9. Biases Hindsight bias - “Should have known better”. Outcome bias - “Since the outcome was bad, the plan was bad”.
- 10. What changed?
- 11. Cynefin Conceptual framework created by Dave Snowden to organize intellectual capital at IBM. Uses quadrants to organize problems by complexity and suggests a course of action.
- 14. Simple/Obvious Sense Categorize Respond Alert: Disk almost full Disk full Prune Docker images Internal webservice is not responding
- 15. Complicated Sense Analyze Respond Failing pipelines ran at same time as other builds Concurrent pipeline collisions cause node resource contention Update pipelines to splay across nodes Increasing CI pipeline failures, happens only during the day
- 16. Complex Probe Sense Respond - Investigate logs - Inspect exponential backoff code - Run load tests - View existing alerts - Analyze performance from load test Add backpressure throttling to discovery service Discovery service became overloaded, triggering cascading failure in other services
- 17. Chaotic Act Sense Respond Move instances to another AZ Still unable to connect Cannot connect in new AZ either Unable to connect to instances in AWS us-east-1a. No AWS service warnings.
- 18. Disorder Reduce Analyze Iterate What do we know for sure? What do we agree on? Move to a quadrant, continue Stems from a lack of agreement on the problem
- 19. Takeaways - Be aware of the limitations of the RCA techniques you use - Emergent behavior arises from complexity and increased rate of change - Consider trying Cynefin to help you approach complex problems
- 20. Thank you! Dustin Collins @dustinmm80