5 whys - The Path to Resolution

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