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How to run a 5
Whys (With Humans, Not Robots)Dan Milstein@danmilDirector of Product Development, Wingu
What Is a 5 Whys
Anyways?• Something you do when your company has badly screwed up• E.g. your CEO demos your cloud storage system to an early prospective customer, and, when he runs a search, it shows other customers’ data (I have done this, it was not awesome)• You get a bunch of people into a room and say: “How on earth did that happen? And how can we make sure it never, ever happens again?”• That’s a 5 Whys (aka, a Post-Mortem)• But, there’s a problem....
Human Beings Will Eff It
Up• Humans (unlike robots) feel this intense emotion called shame• Shame will suggest (strongly) “Slow Down, Stop Making So Many Mistakes”• Aka “Throw overboard everything the Lean Startup tells you is important”• Has potential to be incredibly damaging to your startup• And I have some bad news...
This Emotional Experience Can Not
Be Avoided• I’ve run c. 50 post-mortems, have studied failure... and I still have this emotional reaction• You will, too. And so will your team.• Much more strongly than you realize right now• This is the “Fundamental Attribution Error” (FAE), from psychology• FAE = humans vastly underestimate the power of a situation on our behavior
After Every Axe Murdering...• Have
to, like, hire a new guy, train him on the machine, takes forever• Questions we asked before are now somehow deeply wrong:• “What if we just cut down on the rate, so there’s less axe murdering?”• “Hey, we can train a pool of temps on all the machines, when someone gets killed, we’ll just swap some new guy in, bang, problem solved!”• “How much is it really costing us, anyways?”• These ideas seem obscene, not merely bad
Moral Mindset, Key Words• “Villains”,
“Accusers”, “Authority”, “Punishment”• I believe that most companies, in investigating outages, act much more like they’re looking for an axe murderer, than trying to ﬁx a broken machine
Why It’s Hard• Mindsets control
how we interpret the world...• ...including what people say to us• So, a team sitting there, fearing moral censure, hears you say “We’re not looking to blame anyone”, they just think you’re lying. How could you mean that, when the thing that happened was so terrible and wrong?• The deep trick (and this is the point of this whole presentation, frankly), is that you have to take advantage of the thing that separates humans and robots...
Humor == Breaking Frames• That’s
what humor actually is -- something that stretches or breaks the mental frame that people are using to interpret a situation• So, you use humor to break the frame, release people from the blame/fear/ punishment of the moral mindset, and then refocus them on the economic challenges you’re facing• The humor is, IMHO, not a nice-to-have. It’s absolutely central. I’ve seen smart, caring leaders get this one wrong, and ﬁnish their post-mortems with a room full of tense, closed-up team members (and no good ideas on the table)• Rest of talk is speciﬁc examples of this, but this is the main point
Place The Bad Thing on
a Continuum• Moral mindset is very absolutist: this bad thing is The Worst Thing Ever• I like to say “Okay, well it’s pretty bad, let’s compare it to some things”• Did we irretrievably lose customer data? (I’ve done that, not awesome)• Did we almost get our customer ﬁred by her boss (also, not awesome)• Did we send hundreds of emails to everyone on our customer’s mailing list... but the emails were all question marks? For a customer who was in the proofreading business? (done that, very much not awesome)• People laugh, and then say “Okay, how bad was this, really?” Win.
More Stories of Actual Failures
(Just For Fun)• Did we break our allergies-to-medicines module, and risk having a doctor prescribe the wrong medication to someone?• Did our internet-connected home thermostat system have a server crash, causing all the thermostats to set the temp to the default... of 85 degrees?• Did our high-frequency trading program have ﬂaws that led to our company losing 450 million dollars? (that is a tough one to beat, IMHO)• Collect your own! It’s fun!
How Hindsight Bias Shows up
in a 5 Whys• Someone says “Oh, yeah, I screwed that one up, I knew I had to run the deploy in that one order, and I just forgot. I’m really sorry, I won’t make that mistake again, totally my bad.”• You have to utterly reject this. It’s pure hindsight bias (easy to see errors after the fact, very difﬁcult in the moment).• I say “It’s like we’re saying ‘I was stupid, this one time, and we’ll ﬁx that problem by never being stupid again.’”• Hence: “planning for a future where we’re as stupid as we are today”• aka “Must create a system which is resilient to occasional bouts of really intense stupidity”.
5 Whys Will Highlight That
Your Code is a Mess• E.g. you’ve refactored, and rewritten in python (or node or something), and moved to the cloud, but this 5 whys is making clear that your most important report is still run by a VisualCron job on a Windows server that never quite made it out of the ofﬁce... and someone just tripped on the power cord• Team will feel ashamed, you have to give them license to relish absurdity• I often point out “There are two kinds of startups: the ones that achieve some modest traction on top of a pile of code of which they are vaguely ashamed... and the ones that go out of business. That’s it. No third kind.”• Also sometimes it helps to just laugh: “It’s kind of amazing this works at all”
Handling a Fork in the
Road• Example: bad outage at Wingu: was triggered by a mistake in db access code. But we couldn’t ﬁx it for three hours, because our error reporting system was trying to send us hundreds of emails/minute, so our email provider throttled us, and we didn’t get those email until hours later.• Which is the Root Cause? DB access bug or monitoring failure?• Answer: don’t care about “root causes”. They don’t exist (multiple things conspire for failures to happen). Also, kind of moral/blame-ish.• Ask instead: if we made an incremental improvement in area A or area B, which would prevent the broadest class of problems going ahead?• Much better conversation. Answer here is clear: monitoring.
Photo Credits• “Robot de Martillo”,
by Luis Perez, http://www.ﬂickr.com/photos/pe5pe/2454661748/• “Helios-Factory ﬂoor”, http://commons.wikimedia.org/wiki/File:Helioshall2.jpg• “old machine”, by Jun Aoyama, http://www.ﬂickr.com/photos/jam343/1730140/• “Axe Marks The Spot”, by Alan Levine, http://www.ﬂickr.com/photos/cogdog/4461665810/• “Failboat Has Arrived”, http://www.rotskyinstitute.com/rotsky/wp-content/uploads/2008/02/ failboat2.jpg• “14 plugs but only 6 sockets”, by Jason Rogers, http://www.ﬂickr.com/photos/restlessglobetrotter/ 2661016046/• “Life is like that… a fork in the road… decision required”, by Roger Price, http://www.ﬂickr.com/ photos/rwp-roger/6687024883/