Understand how to use root-cause analysis to analyze problems

1. Using Root Cause Analysis
for Problem Management
Training

2. Purpose of this training
• Show how to use root-cause analysis to
understand problems in our context
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3. Solve problems, not symptoms
• To solve problems, you must make sure that
you understand it:
1. Why it needs to be solved
2. How you will know when it is solved
3. What the root cause is.
• Be careful not to mistake symptoms for cause.
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4. Example
• Problem: Memory leak in server.
• Bad solution: Buy more memory.
• Good solution: Find & fix the source of the
memory leak. Implement tests to detect new
memory leaks in the future.
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5. Systemic problems
• Most problems in
organizations are systemic. The
“system” (the organization) has
a glitch that needs to be fixed.
• Until you find the source of the
glitch, most attempts to fix the
problem will be futile or even
counterproductive.
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6. Problem solving approach
• A3-thinking: yet another output of the
« Kaizen » continuous process improvement
from Toyota Lean methodology.
Analyze and visualize the root cause before
proposing a solution.
 You can do this using cause-effect diagrams,
or stream maps, or fishbone diagrams
Template: http://www.crisp.se/gratis-material-och-guider/a3-template
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7. How to use cause-effect diagram
• Here’s the basic process:
1. Select a problem and write it down.
2. Trace “upwards” to figure out the business consequences, the “visible
damage” that your problem is causing.
3. Trace “downwards” to find the root cause (or causes).
4. Identify and highlight vicious cycles (circular paths)
5. Iterate the above steps a few times to refine and clarify your diagram
6. Decide which root causes to address and how (i.e. which countermeasures
to implement)
7. Follow up and see if it worked. If not, try again.
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8. Example 1: we always miss deadlines (1/3)
• We have a long release cycle and our releases always occur at
a later date than planned.
– So what? Who cares if the releases are delayed? What is the
consequence?
– Can we quantify the problem? This data will help us evaluate how
much effort it is worth spending to solve this problem.
– How will we know when we’ve solved the problem?
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9. Example 1: we always miss deadlines (1/3)
• We have a long release cycle and our releases always occur at
a later date than planned.
– So what? Who cares if the releases are delayed? What is the
consequence?
– Can we quantify the problem? This data will help us evaluate how
much effort it is worth spending to solve this problem.
– How will we know when we’ve solved the problem?
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10. Example 1: we always miss deadlines (2/3)
• Dig towards the roots
– 5 whys
• Why are we missing
deadlines?
• Why? Why? Why? Why?
– Vicious cycles / re-enforcing
loops should start to
appear. Recurring problems
almost always involve
loops.
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11. Example 1: we always miss deadlines (2/3)
• Dig towards the roots
– 5 whys
• Why are we missing
deadlines?
• Why? Why? Why? Why?
– Vicious cycles / re-enforcing
loops should start to
appear. Recurring problems
almost always involve
loops.
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12. Example 1: we always miss deadlines (3/3)
• Identify the root cause(s)
– Go back and ask a few more whys
• Now it’s time to propose countermeasures
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13. Example 1: we always miss deadlines (3/3)
• Identify the root cause(s)
– Go back and ask a few more whys
• Now it’s time to propose countermeasures
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14. Example 2: Lack of TDD or Pair Programming (1/2)
• What is the consequence of not doing pair
programming or TDD? Is lack of TDD and pair
programming really a problem?
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15. Example 2: Lack of TDD or Pair Programming (1/2)
• What is the consequence of not doing pair
programming or TDD? Is lack of TDD and pair
programming really a problem?
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16. Example 2: Lack of TDD or Pair Programming (2/2)
• Why aren’t you pair
programming then?
– 5 Whys
• Identify unexpected
root causes
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17. Example 2: Lack of TDD or Pair Programming (2/2)
• Why aren’t you pair
programming then?
– 5 Whys
• Identify unexpected
root causes
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18. Lots of problems
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19. Practical notes
• Working alone: tool of your choice
(powerpoint, visio, paper board…)
• Working in small groups:
– You can use sticky notes for issues and a
white board
• Working in larger groups: split in
smaller groups focused on a specific
problem. Gather regularly to share
insights.
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20. Pitfalls
• Too many arrows and boxes:
– Remove redundant boxes
– Focus on “depth first”. Don’t write all causes of a problem, write only
the most important one or two, and then keep digging deeper.
– Accept imperfections, a diagram like this will never be perfect.
– Maybe your problem area is too broad, try to limit yourself to a more
narrowly defined problem.
– Split the diagram into pieces.
• Getting personal:
– Treat all problems as systemic!
– Avoid “blame game”.
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21. Summary: Why to use cause-effect diagrams
• Create a common understanding
– Cause-effect diagrams are a very practical collaboration
technique to create a common understanding of a
problem.
• Identify how problems affect the business
– So that you can focus on the most important problems
first and make informed decisions.
• Find root causes
– So that you can maximize the effect of your changes.
• Find vicious cycles
– So that you can break them, or turn them into positive
reinforcing loops (good stuff leading to more good stuff,
instead of bad stuff leading to more bad stuff).
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22. Reference
• http://blog.crisp.se/2009/09/29/henrikkniberg/1254176
460000
– http://www.crisp.se/file-uploads/cause-effect-diagrams.pdf
• http://blog.crisp.se/2012/08/23/henrikkniberg/problem-
solving-template
• http://en.wikipedia.org/wiki/5_Whys
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23. Find out more
• On https://techblog.betclicgroup.com/
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