Shane Chagpar, Kepner-Tregoe

How to find the change that started a mess in times of pressure and panic                          

In the world of solving problems, everyone knows that more often than not, cause comes from change. Something didn’t change and it should have, or something changed in our environment and we would have wished it really didn’t. The worst days are those when a change that was made a long time ago does not take effect until a very recent change combines in a unique way to ruin your day. These changes can be hard to track down, and the resulting delays during an outage only accelerate losses and increase frustration.

Now imagine a sky full of colorful balloons…          

If each of these balloons represented a change on your system, in your organization, or by your peers – how much of the sky would be filled? How fast would new balloons be added forcing others to be pushed back and fly further away?

During a problem, you have but a few crucial moments to ‘look up’ and see the balloons currently in the sky. As a problem solver, you know you must act quickly to decide which of these  balloons you want to grab hold of and examine more closely – hoping that you choose correctly and that the underlying change was a contributor to the root cause of the problem.

Adding to this challenge is that the more time you wait, the balloons move further and further away from you, making them difficult to understand, gather detail on, and grab hold of.

How to pick better balloons

Great problem solvers will gaze at these “change” balloons, seeking the one that will stand out to them. They will scan the sky, often for specific colors their instincts tell them are important, ignoring the other sizes and shapes until almost magically they grab a series of balloons for examination, and declare one as the reason for all the trouble being caused.

How do great problem solvers do this?

When faced with a sea of changes, it’s easy to focus on the biggest, most recent, and closest change to try and examine first. We think those balloons are the easiest to catch and examine, they also look very enticing! For simple problems, often this method can pay off, and the most recent change is the change that caused the issue.

But what about when we have a complicated problem?

If we are to see through the distractions, and ignore balloons that don’t contribute to the problem – we need a method to sort and separate the useful from the useless. In problem solving, one way to do this is to first sort the entire group of changes through distinctions. I’m defining a distinction as something that is special, odd, unusual, or unique that affects the object that has the problem, and is not part of any similar object or objects that could be experiencing the problem but do not. This could include areas that are unique to where the problem is occurring vs. where it could be occurring but is not, when the problem happened vs. when it could have happened but is not, and what users or equipment are affected by the problem vs. what could have been affected but was not.

Sometimes there will be a lot of distinctions, and sometimes there will be just a few. Don’t worry about this – it is quality over quantity at this stage in problem solving.

Anchoring balloons

For every unique property that is found in the distinctions exercise, we then place an anchor firmly in the ground and label it with the name of the unique property or distinction found. For example, the users having the issue are “only on the 3rd floor”, or the part in question that is failing is connected to a “separate pneumatic line”, the ingredients used in this pharmaceutical drug has a “different binder”, or the financial product being complained about is “only offered to students”. These would make excellent starting anchors!

After creating and naming these anchors, it’s now time to turn to the sky and examine all those change balloons once again. Yes, they are farther away than when we started since time has passed during our anchor activity, but now we can quickly scan the sky again, this time for changes that match or are closely related to an anchor name only. Did we recently change bulbs on the 3rd floor? How about use a new shipping supplier for our binder ingredients? For any of these change balloons, tie them to the anchor, and repeat scanning until all balloons related to an anchor are safely tied down.

Forming ideas

At this point, we have a few anchors on the ground, some with no balloons attached, perhaps some with many, and maybe a few with only one. It’s now time to come up with solid ideas as to why a problem occurred. To do this, we can simply brainstorm using our knowledge and experience to form ideas based on the balloons we have tied down in front of us. Feel free to mix and match ideas, or even use the names of the anchors to spawn new thoughts. One thing is for sure, everything that is important is now facing you, and you don’t have to worry now about chasing runaway balloons!

KT has a powerful toolkit for root cause analysis and preventing future problems