When I joined Amazon in 1999, our software and fulfillment network was swamped by the growth in demand. We were barely surviving. We couldn’t be operationally excellent until we dug ourselves out of that hole and built systems and processes to meet the demand.
Fast forward two decades, and Amazon is an example of Operational Excellence. It didn’t happen in one day, week, month, or year… it was a series of steps, processes, actions, and decisions over many years. One of the steps we took to get there was to apply proven techniques from other excellent companies, namely Toyota.
One of the methods they invented at Toyota is the “Five Whys” method for root cause analysis of failures. Here is how we used it and a template for you to use:
Whenever there was a significant failure in the customer experience, we would run a formal investigation. This meant not just asking why the surface-level effect occurred, but also why the condition that allowed it existed in the first place, why the condition that allowed THAT condition existed, and so on.
Asking “why” five times was a forcing function that pushed teams to reach the root cause.
Then, once we knew exactly what happened, why it happened, and why our processes, rules, or systems allowed it, we made a plan to fix the root cause so it could never happen again. By the way, committing to following through on those two steps — much easier said than done.
The output was a CoE (Correction of Error) document (6 pages or less) that described the issue, the actual root cause (which was often very different than the surface-level failure), and the long-term fix. These documents were not optional and they would be reviewed at the VP level or in some cases, the CEO level.
Here is how to structure a CoE doc (copy and paste this into a doc):
—
[Insert Topic Here] Correction of Errors
1. Description of problem and its impact
a. Description
b. Data Collected to demonstrate the problem
c. Customer Impact
d. Financial Impact
2. Root causes (use the 5 whys method)
a. Why did the error occur?
b. Why did that condition exist?
c. Why did the above condition exist?
d. Why did the above condition exist?
e. Why did the above condition exist?
Answering these questions five levels deep should lead you to the root cause of the issue, though the tool does not tell you what questions to ask or how to find the answers, so it is not a guarantee of success.
3. Corrective actions taken
a.
b.
c.
etc,
4. Lessons learned (bad and good)
Here are the errors we made and/or hard lessons we learned:
a.
b.
c.
d.
e.
Here are some things we did well:
a.
b.
c.
To better understand the CoE process, read a sample CoE report on our website:
https://lnkd.in/gF-CPb8s
