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THE CURSE OF THE FIVE BLAMES

When teams first adopt Five Whys as a problem-solving tool, they encounter some common pitfalls. We need systems like Five Whys to overcome our psychological limitations because we tend to overreact to what’s happening in the moment. We also tend to get frustrated if things happen that we did not anticipate.

When the Five Whys approach goes awry, I call it the Five Blames. Instead of asking why repeatedly in an attempt to understand what went wrong, frustrated teammates start pointing fingers at each other, trying to decide who is at fault. Instead of using the Five Whys to find and fix problems, managers and employees can fall into the trap of using the Five Blames as a means for venting their frustrations and calling out colleagues for systemic failures. Although it’s human nature to assume that when we see a mistake, it’s due to defects in someone else’s department, knowledge, or character, the goal of the Five Whys is to help us see the objective truth that chronic problems are caused by bad process, not bad people, and remedy them accordingly.

I recommend several tactics for escaping the Five Blames. The first is to make sure that everyone affected by the problem is in the room during the analysis of the root cause. The meeting should include anyone who discovered or diagnosed the problem, including customer service representatives who fielded the calls, if possible. It should include anyone who tried to fix the symptom as well as anyone who worked on the subsystems or features involved. If the problem was escalated to senior management, the decision makers who were involved in the escalation should be present as well.

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This may make for a crowded room, but it’s essential. In my experience, whoever is left out of the discussion ends up being the target for blame. This is just as damaging whether the scapegoat is a junior employee or the CEO. When it’s a junior employee, it’s all too easy to believe that that person is replaceable. If the CEO is not present, it’s all too easy to assume that his or her behavior is unchangeable. Neither presumption is usually correct.

When blame inevitably arises, the most senior people in the room should repeat this mantra: if a mistake happens, shame on us for making it so easy to make that mistake. In a Five Whys analysis, we want to have a systems-level view as much as possible.

Here’s a situation in which this mantra came in handy. Because of the training process we had developed at IMVU through the Five Whys, we routinely asked new engineers to make a change to the production environment on their first day. For engineers trained in traditional development methods, this was often frightening. They would ask, “What will happen to me if I accidentally disrupt or stop the production process?” In their previous jobs, that was a mistake that could get them fired. At IMVU we told new hires, “If our production process is so fragile that you can break it on your very first day of work, shame on us for making it so easy to do so.” If they did manage to break it, we immediately would have them lead the effort to fix the problem as well as the effort to prevent the next person from repeating their mistake.

For new hires who came from companies with a very different culture, this was often a stressful initiation, but everyone came through it with a visceral understanding of our values. Bit by bit, system by system, those small investments added up to a robust product development process that allowed all our employees to work more creatively, with greatly reduced fear.

Getting Started

Here are a few tips on how to get started with the Five Whys that are based on my experience introducing this technique at many other companies.

For the Five Whys to work properly, there are rules that must be followed. For example, the Five Whys requires an environment of mutual trust and empowerment. In situations in which this is lacking, the complexity of Five Whys can be overwhelming. In such situations, I’ve often used a simplified version that still allows teams to focus on analyzing root causes while developing the muscles they’ll need later to tackle the full-blown method.

I ask teams to adopt these simple rules:

The first rule encourages people to get used to being compassionate about mistakes, especially the mistakes of others. Remember, most mistakes are caused by flawed systems, not bad people. The second rule gets the team started making proportional investments in prevention.

This simplified system works well. In fact, we used it at IMVU in the days before I discovered the Five Whys and the Toyota Production System. However, such a simplified system does not work effectively over the long term, as I found out firsthand. In fact, that was one of the things that drove me to first learn about lean production.

The strength and weakness of the simplified system is that it invites questions such as What counts as the same problem? What kinds of mistakes should we focus on? and Should we fix this individual problem or try to prevent a whole category of related problems? For a team that is just getting started, these questions are thought-provoking and can lay the groundwork for more elaborate methods to come. Ultimately, though, they do need answering. They need a complete adaptive process such as the Five Whys.

Facing Unpleasant Truths

You will need to be prepared for the fact that Five Whys is going to turn up unpleasant facts about your organization, especially at the beginning. It is going to call for investments in prevention that come at the expense of time and money that could be invested in new products or features. Under pressure, teams may feel that they don’t have time to waste on analyzing root causes even though it would give them more time in the long term. The process sometimes will devolve into the Five Blames. At all these junctures, it is essential that someone with sufficient authority be present to insist that the process be followed, that its recommendations be implemented, and to act as a referee if disagreements flare up. Building an adaptive organization, in other words, requires executive leadership to sponsor and support the process.

Often, individual contributors at startups come to my workshops, eager to get started with the Five Whys. I caution against attempting to do that if they do not have the buy-in of the manager or team leader. Proceed cautiously if you find yourself in this situation. It may not be possible to get the entire team together for a true Five Whys inquiry, but you can always follow the simple two-rule version in your own work. Whenever something goes wrong, ask yourself: How could I prevent myself from being in this situation ever again?

Start Small, Be Specific

Once you are ready to begin, I recommend starting with a narrowly targeted class of symptoms. For example, the first time I used the Five Whys successfully, I used it to diagnose problems with one of our internal testing tools that did not affect customers directly. It may be tempting to start with something large and important because that is where most of the time is being wasted as a result of a flawed process, but it is also where the pressure will be greatest. When the stakes are high, the Five Whys can devolve into the Five Blames quickly. It’s better to give the team a chance to learn how to do the process first and then expand into higher-stakes areas later.

The more specific the symptoms are, the easier it will be for everyone to recognize when it’s time to schedule a Five Whys meeting. Say you want to use the Five Whys to address billing complaints from customers. In that case, pick a date after which all billing complaints will trigger a Five Whys meeting automatically. Note that this requires that there be a small enough volume of complaints that having this meeting every time one comes in is practical. If there are already too many complaints, pick a subset on which you want to focus. Make sure that the rule that determines which kinds of complaints trigger a Five Whys meeting is simple and ironclad. For example, you might decide that every complaint involving a credit card transaction will be investigated. That’s an easy rule to follow. Don’t pick a rule that is ambiguous.

At first, the temptation may be to make radical and deep changes to every billing system and process. Don’t. Instead, keep the meetings short and pick relatively simple changes at each of the five levels of the inquiry. Over time, as the team gets more comfortable with the process, you can expand it to include more and more types of billing complaints and then to other kinds of problems.

Appoint a Five Whys Master

To facilitate learning, I have found it helpful to appoint a Five Whys master for each area in which the method is being used. This individual is tasked with being the moderator for each Five Whys meeting, making decisions about which prevention steps to take, and assigning the follow-up work from that meeting. The master must be senior enough to have the authority to ensure that those assignments get done but should not be so senior that he or she will not be able to be present at the meetings because of conflicting responsibilities. The Five Whys master is the point person in terms of accountability; he or she is the primary change agent. People in this position can assess how well the meetings are going and whether the prevention investments that are being made are paying off.