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