每日原则:问题的根源不是一次行动而是一个原因
解释问题的根源时,通常用形容词而不是动词来描述,所以要多问“为什么”来寻求问题的本质原因。大部分事情做成或没做成的原因是有人决定按某种方式做或者不做,因此多数问题的根源可以追究到行事具有特定规律的具体的人身上。当然,即使是可信度高的人偶尔也会出错,如果是这样,是情有可原的。但是如果问题能归结到某人身上,你必须问为什么此人会犯错——你必须准确诊断一个人的错误,如同准确诊断机器某个部件的故障一样。
一个发现问题根源的过程会经历如下对话:
要考虑所问的问题多大程度上涉及个人隐私。不要仅仅停留在问“因为哈里的程序设计不好”,你必须深入探究以便了解员工和/或设计在怎么样的情况下导致了失败。这对于诊断人和责任人都不容易,常常会导致人们提出各种各样不相干的细节。人们通常会故意把局面搅乱来掩饰自己的错误,对此你要保持警惕。
Root causes are described in adjectives, not verbs, so keep asking "why" to get at them. Since most things are done or not done because someone decided to do them or not do them in a certain way, most root causes can be traced to specific people who have specific patterns of behavior. Of course, a normally reliable person can make the occasional error and if that's the case, then it can be forgiven, but when a problem is attributable to a person, you have to ask why they made the mistake--and you have to be as accurate in diagnosing a fault in a person as you would be if he or she were a piece of equipment.
A root cause discovery process might proceed like this:
The problem was due to bad programming.
Why was there bad programming?
Because Harry programmed it badly.
Why did Harry program it badly?
Because he wasn't well trained and because he was in a rush.
Why wasn't he well trained?
Did his manager know that he wasn't well trained and let him do the job anyway, or did he not know?
Consider how personal the questioning is. It doesn't stop at "Because Harry programmed it badly." You must go deeper in order to understand what about the people and/or the design led to the failure. This is difficult for both the diagnoser and the RPs, and it often results in people bringing up all kinds of irrelevant details. Be on your guard because people will often look to cover themselves by diving into the weeds.
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