FiveWhysRootCause Analysiswith IshikawasFishbone Diagram

MakingtheHurtGoAway
RootCauseAnalysisbasicsfortechnicalmanagers withoutfluff,mumbojumbo,orvigorousselflove. DavidM.Russell 12/14/2008

 Thingsgowrongthatsjustafactoflife.To paraphrasetheinfamousbumpersticker, Stuffhappens.Intheworldofsoftware projects,thatstuffconsistsofbugs(software defects),bad/unclearrequirements,missed deliverydates,inappropriateexpectationsand soforth.Andwhenthosethingsgowrong,all toofrequently,thesymptomsendupgetting treated,onlytoreturninthefuturewhenthe realproblemmanifests itselfagain. Ifyoureutilizingstatisticalprocesscontrolin yoursoftwaredevelopmentenvironment, yourerunningashopinthetoppercentileor twoandprobablyhavethismaterialdowncold. Thispaperisforthosewhoarerunningshops thathaventquitemadeittothatpoint.Maybe yourcompanyhasntinvestedintheanalysis necessaryforpropermetrics.Perhapsyour entiremanagementteamconsistsofex developersandother technicalstaffwhohave neverhadformalexposureto Goodnews: Any theseconcepts.Maybe applicationofRoot everyonesonboardand CauseAnalysis wantstodoit,butthefearof techniquescanhelp highupfrontcostskeep everyoneparalyzed. tremendouslyinmaking FiveWhysRootCauseAnalysiswithIshikawasFishboneDiagram

Tomakemattersworse, handsonITmanagers (likeme)canendup gettingsomiredinthe detailsofcodereviews, projectplans,and bigproblemsgoaway Well,withouthavingtodig productionrelatedissues intocontrolcharts, thatitsveryeasytomiss evenifyoureanovice. outoneasyfixestothe histograms,andvariance bigproblemshidingin measuredinstandard yourshopwhile deviationsfromthemean, hereareafewquickwaystothinkaboutthe distractedbyminutiae.Ourtraininginlogic problemsinyourworldandtodetermine makesusdig,dig,digtogettothesolutions whethersomethingisworthyofRootCause welookatthesubnet,thentherouter,thenthe Analysis. individualcomputer;weanalyzetheerror message,thentheclass,thenthelineofcode. Buttheresgoodnews:AnyapplicationofRoot CauseAnalysis(RCA,asweinsiderscallit youreonetoo,now)techniquescanhelp tremendouslyinmakingthesebigproblemsgo awayevenifyoureanoviceatthecraft. So,howdoessomeonewithapenchantfor perfectionismpullbackfarenoughtoseethe bigpicture?HeresthethoughtprocessIuse determinethemostappropriatepartsofthe processtooptimizethroughLeanProcess Improvementtechniques:

3EasyWaystoTellWhentoUse RootCauseAnalysis:

1. Aneventkeepshappeningagainand again(eg:longtestcycles,highvolume ofdefectsforeachrelease) 2. Relatedeventsappeartohappen regularly(eg:learningofnew requirementswhiletheproductis undertest,missedprojectdelivery dates)

 ambitiouswhenlearninganewskill. MaslowsGoldenHammer,Whenallyou haveisahammer,everyproblembeginsto looklikeanail,canresultinunnecessary investigationintocausalityforthingswhich haveverylittleincommonotherthan See,youdonthavetoimplementfancy timing. systems,trainyourstaff,orcollectmetricsfora Notacostlyproblem:Whenfixingthe year(hopingpeopledontskewthenumbersby problemcostsmorethantheproblemitself, gamingthesystem)inordertofind whytrytofixit?Thisisnotmeanttoserve opportunitiestosaveabundle.Imsureafew asanexcusetoignorehugegroupsof minutesofmoderateconcentrationwill relatedsmallthings,butrathertoensure generatequiteafewideasofwhatmightbe thattheRCAprocessdoesntfallflatonits worthyofinvestigation. facebecauseitstoo costlytokickoffor Armedwiththoseideas, maintain.Putting5 hereareacoupleof Youdonthaveto peopleinameetingfor pointstoconsiderwhen afewdaysto implementfancysystems determiningwhatsripe brainstormasolutionto forRootCauseAnalysis. orcollectmetricsfora a$1,000problem yeartofind doesntmakesenseor WhenisRootCause opportunitiestosavea centsandwillonly Analysisthe meritnegative bundle. WRONGanswer? attentiontoyour Isolatedconditions: otherwiseprudent Someproblemsare effort. soisolated,even UpperManagementdoesntwantthe thoughexpensive,thatthebestwayto truth:Theunfortunaterealityisthat handletheeventispreparationratherthan sometimesthepeopleatthetoparethe resolution.Itmakessensetodetermine rootcause.Theirmandates,direction,or thisasquicklyaspossible,ratherthan pettyfoiblescouldverywellbethereason wasteagreatdealoftimediggingin.For whyanumberofthingskeephappening example,ahurricaneknocksoutyourdata againandagain.Highturnover, center.Doesitmakesensetodigintothe counterproductivepolitics,andbadvendor rootcauseofthehurricane,ortojustdo selectionhaveatendencytocomefrom somethingtominimizeyourlosses? uppermanagementwhosimplydoesnt Unrelatedevents:Correlationdoesnot carewhatyou,thepeons,thinkabouttheir implycausation.Thisfallacyissotimelessit actions.Ifyouranalysisleadsyoutothe hasbeenrecordedinLatinbyancient conclusionthatuppermanagementisto scholars:CumHocErgoPropterHoc. blame,youshouldreconsider Sometimes,managerscangetalittle 3. Certaininfrequenteventsarevery impactful(eg:peoplewithalotof knowledgequit,sourcecontrol needstoberestoredfromlast monthstape) FiveWhysRootCauseAnalysiswithIshikawasFishboneDiagram

 communicatingthisand/oryourpositionat thefirminquestion. Ihave,inthepursuitofpureknowledgeand thespiritoftotalquality,mistakenlyshared findingsthatuppermanagementdidnt wanttohearonmorethanoneoccasion. Unfortunately,evenwhenyouretold thinkoutoftheboxoryourenotgoing tohurtmyfeelings,theymaynothave expectedtheresultsyourresearch provides.WhatIhavededucedfrommy experiencesandthoserelatedtomeisthat whatuppermanagementfrequentlywants isforsomeoneelse(us)tofixthe problemwithinanarrowedscopeofcontrol notforustotellthemthattheyarethe problem.Theywantsomeonefromthe outsidetocometothesameconclusions theyalreadyhaveandusestatisticsand researchtoputaribbonandbowontheir presentationtotheBoardofDirectorsor whatnot.Itiswisetoavoidthislandmine. lastrelease.Thisistheeffectpartofthe causeandeffectdiagram. FiveWhysRootCauseAnalysiswithIshikawasFishboneDiagram

Fromthatmainline,createbranchesforvarious causecategories.Thesecaneitherbeplaced firsttofuelbrainstorming,ordeducedasyougo throughtheprocessandcleanedupalongthe way. Herearesomecommonlyusedcausebranches whenperformingFishboneAnalysis: The8P's Procedures,People,Price,Promotion, Processes,Plant,Product,andPolicies The6M's Machinery,Materials,Maintenance, Methods,MotherNature,andMan. The4S's Skills,Surroundings,Systems,andSuppliers.

TheFishboneDiagram
TheFishboneDiagramisaneatlittlevisualtool. Ithelpswiththebrainstormingprocessof determiningcausesandrootcauses.Italso providesaquickvisualrepresentationofcause density.Itscalledthefishbonediagram, becausewhenyourestartingout,ithasa sidewaytreelooktoitwhichresemblesafish skeleton.Sometimesitscalledacauseand effectdiagramorIshikawadiagrambecauseof whatitdepictsandwhocameupwiththething, respectively. Todrawafishbonediagram,drawaline pointingofftotherightwiththeproblem statement,suchasToomanydefectsinthe

Thisiswhenthecauseandeffectdiagramstarts tolooklikeafishbonediagram.Afterthispoint, thediagramstopsresemblingafishbonepretty quickly.Isupposethatswhenitevolvesintoa fullfledgedIshikawadiagram.

 FiveWhysRootCauseAnalysiswithIshikawasFishboneDiagram

TheFiveWhysMethodofFishbone Analysis
Withachildsinquisitiveness,brainstormideas ofwhatmighthavecausedeacheventyoure lookingintobyaskingwhy,why,why? Thenumberfivein5whysissomewhat arbitraryalongthelinesoftheluckynumber sevenortheunluckynumberthirteen.Thinkof fiveasaruleofthumb,thepointistokeep theeyeontheprizetherootcause. Whetherthattakesthreewhysortwenty whys,keepgoinguntilyouredone. Workingyourwaydownthefishbone,keep askingwhy,allthewhileaddingmoreandmore linesoffoflinesexplainingtherationalefor eacheventdownthechain,creatingachart whichlooksabitlikethisexample.

deepestlevel,isassociatedwiththelargest volumeofevents. Sometimes,itsobviousfromalloftheresults wheretheproblemlies,andsometimesyoull havetopruneoutthesillyordistractingones. Bearinmindthattherecanbemorethanone rootcause.Sometimes,severalrelated causesactinconcert,creatingaperfectstorm. Catastrophicfailures,forexample,seldomoccur becauseonepersonfailedtoperformtheirjob adequately.Usually,itsbecauseseveralpeople orprocessesatverykeypointsdidntworkas expected.So,dontbeatyourselfuplookingfor thefabledrootcause,forsakingallothers. Youmighthaveacoupleofcontendersthatare allworthyofconsideration. Youmightevenfindthatanentirecategoryis therootcause,asinlackofsufficient managementtrainingofaparticular department,orlackofaccountabilityina certaingroup,andsoforth.Whenyousee (ratioexaggeratedforeffect)4,000itemsinone categoryandonlyfifteeninalltheothers,it shouldbecomeratherapparentwhere problemsolvingtalentsshouldbefocused. Thisprocessoflookingforabiggroupof problemsinoneplaceconceptiscalled ParetoAnalysis.Youmayalreadyknowofthe ParetoPrinciplebyitsmorecommonname, the80/20rule.Themajorpremisebehind ParetoAnalysisisthatyoushouldspendyour timetryingtofigureoutthatonething(orsmall setofthings)whichwillhavethegreatest impactifyoufixjustthat. IfyoudontapplytheParetoPrincipletoyour analysis,youruntheriskofAnalysisParalysis thatswhereyouspendsomuchtimethinking

Asanexample,inthecaseofalargenumberof softwaredefects,onemightaskwhyeachof theindividualeventsoccurred.Fromeach attributedcause,continuetoaskhowthat particularsymptomorsituationemerged.And soonuntilyougettowhatcausedthatproblem inthefirstplace.

TheRootCause
Now,whenyouveworkedthroughallofthe individualeventsandallofthecauses suspectedgobackthroughthebrainstormed listandfigureoutwhichofthose,atthe

 abouttheproblemthatyouneverendupdoing anythingaboutitwatchoutforthis,itsa reallybigtimewaster.AsVoltairesaid, perfectionistheenemyofgoodenough.You needjustenoughinformationtodosomething abouttheproblem. arethatyourproblemhastodowithpeople andprocessesratherthanhowquicklythose peopleexecuteprocesses.Softwareshouldbe usedtospeedupthingsthatarealreadygoing well,ratherthantoimposeanintendedchange. FiveWhysRootCauseAnalysiswithIshikawasFishboneDiagram

WorkingthePlan
Makeithappen.Trythechangeswithone grouponpaper.Pickagroupwhoarereally dedicatedtomakingthingsbetter,ratherthan thegroupwhoneeditmost.Thegroupinneed ofthemosthelpmayneedthathelpforfar morereasonsthanthoseaddressedbyyour newplan. Refineyourchangesasyou learnmoreaboutyour successesandsetbackswith yourtestgroup. Youmayfindwidespread adoptioneasierwithalittle automationtoreducethe timeittakesforpeopleto comeuptospeedonthe newdirection.

BrainstormingSolutions

AsPeterDrucker,fatherofmodern management,hassaid,Plansareonlygood intentionsunlesstheyimmediatelydegenerate intohardwork.Onceyoucomeupwiththe rootcause(s),itsimperativetoworkonaplan toaddressthosecauses.Trytocomeupwith easythingstodo(orstopdoing)thatwillknock outamajorityofyour rootcausesorthe singularrootcausemost Plansareonlygood ofthetime. Becarefulthatyour answerisntmore process.Sadly,youcant testqualityintoa process.Asaresult,its mosteffectivetofind waystoimprovethework inthefirstplacerather thanchecktomakesureitgotdone.

intentionsunlessthey immediatelydegenerate intohardwork ~PeterDrucker viaFamousQuotes.net

PlanningtheWork
Onceyouhaveoneortwofairlyinexpensive waystoaddressyourrootcause,workoutan incrementalplanforputtingthosechangesin place.Doitfast,butdoitsmall,especiallyat first.Dontbeafraidtostartsmall.Itsbetter todotherightthingslowlythantodothe wrongthingwithadeafeningthunderclap. WARNING:ResistALLtemptationtocreate moresoftwaretosolvetheproblem.Again, bewareMaslowsGoldenHammer.Chances

Onceyouveproventhat yourplanworksinasmaller environment,youveironedoutallofthe wrinkles,andyouhaveawayforpeopleto executethenewplanwithminimaldiscomfort yourereadytorollitoutforthebigshowand reallyhaveanimpact.Broadcastyourroot causeanalysis,yourfindings,yoursolution,and yourinitialresultsandotherswillbegforyour assistancetosolvetheproblemintheirpartof theorganization.

 FiveWhysRootCauseAnalysiswithIshikawasFishboneDiagram

Furtherreading:
RootCauseAnalysis FishboneDiagrams TheParetoPrinciple QuotesbyKaoruIshikawa MaslowsGoldenHammer AnalysisParalysis

AbouttheAuthor:
DavidRussellisa ManagementConsultantin CentralFloridaspecializing inSoftwareDevelopment organizations.Davidhelps companiesbuildand improvesoftwareteams whiledeliveringmeaningful productsthatsatisfyallstakeholdersontime andonbudget.FollowhimonTwitterat Twitter.com/DaivRawks.