5 whys - The Path to Resolution
Post on 05-Dec-2014
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5 WHYS
THE PATH TO RESOLUTION
CAUSE AND EFFECT
$H!T HAPPENS • Soluto 62 hours outage
http://blog.soluto.com/2013/01/an-apology-from-the-soluto-team
• Adobe accounts hacked data exposed for 3M customers http://www.theverge.com/2013/10/3/4800042/adobe-suffers-cyber-attack-millions-of-customers-affected
• Knight 450M$ loss because of a bad rollouthttp://dealbook.nytimes.com/2012/08/02/trying-to-be-nimble-knight-capital-stumbles
• Plenty of more …
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-whys-with-humans-not-robots
http://www.reversim.com/2011/10/109-final-class-10.html
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