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FINDING THE “ROOT” IN ROOT CAUSE ANALYSIS

– A CLIENT CASE

MATT FOURIE
THINKING DIMENSIONS
Some of our recent
clients...
Barclays IT
Macquarie ITG
Unisys
Woolworths IT
SGX IT
SITA Global
BT Financial
McDonalds IT
Queensland Police IT
DBS IT
Lockheed Martin Space Systems

•  Thinking Dimensions
International - operating
KEPNERandFOURIE RCA
company initiatives for the last
25 years
•  Specializes in RCA
Methodology for IT Incidents,
Problems and Projects
AGENDA
“Most incident
investigators ask
the wrong
questions, so do not
change your people
but change the
questions they are
asking”

• 
• 
• 
• 

Introduction
Introduce Client Situation
The Three Skills sets
The Common Process and Language

• 
• 

Technical Cause Analysis
Root Cause Components

• 
• 

Client outcomes
Questions & answers
Investigation Info
“It takes a company without a formal and
effective Root Cause Analysis culture up
to 23 days to repair service incidents”
Aberdeen Group – Boston 2010
AGENDA
“Most incident
investigators ask
the wrong
questions, so do not
change your people
but change the
questions they are
asking”

• 
• 
• 
• 

Introduction
Introduce Client Situation
The Three Skills sets
The Common Process and Language

• 
• 

Technical Cause Analysis
Root Cause Components

• 
• 

Client outcomes
Questions & answers
Client Case - PM Improvement
International
Investment
Bank’s IT PM
Division
2009-2012

• 
• 
• 
• 
• 

Lack of Stakeholder commitment
Poor management of information
Working with poor quality information
Poor problem investigation support
Not really solving problems
permanently
Actions taken…
•  For P1 & 2 Incidents a PM was assigned immediately
•  All Incident & Problem Management Staff trained in some
common process
•  Embedded the tools and templates into existing process to
make handover seamless
•  Used in-house facilitators to lead PM teams in a very strong
and decisive way
AGENDA
“Most incident
investigators ask
the wrong
questions, so do not
change your people
but change the
questions they are
asking”

• 
• 
• 
• 

Introduction
Introduce Client Situation
The Three Skills sets
The Common Process and Language

• 
• 

Technical Cause Analysis
Root Cause Components

• 
• 

Client outcomes
Questions & answers
PAST	
  

NOW	
  

FUTURE	
  

STANDARD

TECHNICAL	
  CAUSE	
  
ANALYSIS	
  

INCIDENT	
  RESTORATION	
  

ROOT	
  CAUSE	
  ANALYSIS	
  
AGENDA
“Most incident
investigators ask
the wrong
questions, so do not
change your people
but change the
questions they are
asking”

• 
• 
• 
• 

Introduction
Introduce Client Situation
The Three Skills sets
The Common Process and Language

• 
• 

Technical Cause Analysis
Root Cause Components

• 
• 

Client outcomes
Questions & answers
Common process
• 
Step	
  1:	
  

	
  IdenBfy	
  Problem	
  
	
  SituaBon	
  

• 
Step	
  2:	
  

	
  Gather	
  Incident	
  	
  	
  	
  	
  	
  	
  
	
  InformaBon	
  

• 
Step	
  3:	
  

	
  Analyse	
  Incident	
  
	
  InformaBon	
  

Step	
  4:	
  

	
  Determine	
  Conclusion	
  

Everybody uses the same
process for finding causes and
solutions
The process determines which
questions to ask at each step
for each type of incident
investigation approach
Designed for minimalistic
information combined with a
good focus to provide quick
answers
AGENDA
“Most incident
investigators ask
the wrong
questions, so do not
change your people
but change the
questions they are
asking”

• 
• 
• 
• 

Introduction
Introduce Client Situation
The Three Skills sets
The Common Process and Language

• 
• 

Technical Cause Analysis
Root Cause Components

• 
• 

Client outcomes
Questions & answers
Extreme Focus With “Specificity”
Object	
  
Servers	
  

Fault	
  
Not	
  communicaBng	
  
Data	
  not	
  transferred	
  
	
  
Sent	
  but	
  not	
  received	
  
by	
  receiving	
  servers	
  

Data	
  for	
  Large	
  Outlets	
   Not	
  received	
  
Sales	
  turnover	
  
numbers	
  for	
  Large	
  
Outlets	
  

Not	
  received	
  

Specificity Rules
• One object one fault
• Single-minded & simplistic
• Highly focused
• Must find the correct entry
point
• Ask a question – expect an
answer
Extreme Focus With “Specificity”
Object
Murex Chip

Fault
Produces latency
Transactions
queuing up
TX’s taking longer
than 100
milliseconds

Transactions

Takes longer to
process

“Futures”
transactions

Takes longer to
process

Specificity Rules
• One object one fault
• Single-minded & simplistic
• Highly focused
• Must find the correct entry
point
• Ask a question – expect an
answer
Thinking more specifically…
Incident
Statement

Technical
Cause

Root Cause

Internet
Banking
Degrading

New
Integrative testing
browser
not done properly
configurati
on issue

Encrypted
“hello”
message

‘Beta’
Policy
Certificate requirements for
used
“production”
Thinking more specifically…
Incident	
  Statement	
   Technical	
  Cause	
  

G-­‐Force	
  
System	
  
Freezing	
  
G-­‐Force	
  SQL	
  
DB	
  thread	
  
count	
  
exceeding	
  

Root	
  Cause	
  

High	
  volume	
   Too	
  many	
  
users	
  allowed	
  
access	
  
G-­‐Force	
  
Vendor	
  
program	
  not	
   implemented	
  
closing	
  out	
  
an	
  untested	
  
threads	
  
program	
  
Crea:ng	
  Intelligence	
  
DATA	
  
IS	
  

INFORMATI
ON	
  
BUT	
  NOT	
  

KNOWLEDGE	
  
WHY	
  NOT	
  

APAC	
  
users	
  

Freezing	
  

Different	
  
rouBng	
  
SSL	
  
handshake	
  

USA,	
  UK	
  

Volume?	
  

Started	
  
Oct	
  1	
  

Before	
  

ADSL	
  lines	
  

Awer	
  4pm	
  	
  

New	
  
passwords	
  

Internet	
  
Banking	
  
Slow	
  

ConBnuou

Intranet	
  
Banking	
  

Unexpected Outcomes
• “BUT NOT” clarifies the
facts
• Creates a curious “contrast”
• Looking at answers at a
“granular level”
• Stimulates deductive
reasoning
Example of templates with questions
“Minimalistic principle”..
•  Only need to analyse the information that
would be relevant to the incident
•  Worked questions within a customised
“factor analysis” framework
•  Get a quick factual “snapshot” of the
characteristics of the incident and then
use SME experience and gut feel to
explain the snapshot
•  Test SME inputs against logic of snapshot

“Too much information
can cause confusion.
The key is to get all the
relevant information only
and that is normally
substantially less than
gathering all the
Information.”
Innovation – the FreeZone
thinking experience.
by Kepner & Fourie
Snapshot info for causes
IS	
  

BUT	
  
NOT	
  

WHY	
  
NOT	
  

OBJECT – What object and which other object(s) not?
FAULT – What fault and which other typical faults not?

OBJECT	
  

USERS – Who has the problem and who does not?

FAULT	
  

WHERE – Where are these users and where could they
have been but are not?

USERS	
  
WHERE	
  
TIMING	
  
PATTER
N	
  
CYCLE	
  

TIMING – When did it happen first time and when not?
PATTERN – What is the pattern of faults and what could
it have been but is not?
CYCLE – In which cycle does the problem occur and in
which cycle does it not occur?
CauseWise sample
	
  
DIMENSIO
N	
  

Object	
  
Fault	
  
Loc	
  of	
  
Object	
  
Timing	
  
Pahern	
  
Life	
  
Cycle	
  
Phase	
  
of	
  
Work	
  

IS	
  

BUT	
  NOT	
  

WHY	
  NOT	
  

Possible	
  Causes	
  &	
  Tes:ng	
  
CauseWise sample
	
  
DIMENSIO
N	
  

Object	
  
Fault	
  
Loc	
  of	
  
Object	
  
Timing	
  
Pahern	
  
Life	
  
Cycle	
  
Phase	
  
of	
  
Work	
  

IS	
  
Fireburst	
  V2.0	
  
connecBon	
  	
  

BUT	
  NOT	
  

WHY	
  NOT	
  

Possible	
  Causes	
  &	
  Tes:ng	
  
 
DIMENSIO
N	
  

Object	
  

Fault	
  
Loc	
  of	
  
Object	
  
Timing	
  
Pahern	
  
Life	
  
Cycle	
  
Phase	
  
of	
  
Work	
  

IS	
  
Fireburst	
  V2.0	
  
connecBon	
  	
  

BUT	
  NOT	
  
E-­‐Express,	
  
Mango	
  
connecBons	
  

WHY	
  NOT	
  

Possible	
  Causes	
  &	
  Tes:ng	
  
 
DIMENSIO
N	
  

Object	
  

Fault	
  
Loc	
  of	
  
Object	
  
Timing	
  
Pahern	
  
Life	
  
Cycle	
  
Phase	
  
of	
  
Work	
  

IS	
  
Fireburst	
  V2.0	
  
connecBon	
  	
  

BUT	
  NOT	
  
E-­‐Express,	
  
Mango	
  
connecBons	
  

WHY	
  NOT	
  
F/B	
  upgrade	
  from	
  V1	
  
to	
  V2,	
  Poor	
  tesBng	
  
issue	
  

Possible	
  Causes	
  &	
  Tes:ng	
  
DIMENSI
ON

IS

BUT NOT

WHY NOT

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

Loc of
Objec
t
Timin
g
Patter
n
Life
Cycle
Phase

Possible Causes &
Testing
DIMENSI
ON

IS

BUT NOT

WHY NOT

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

Loc of
Objec
t

ANZ, USA,
UK

Asia

LAN, Proxy server
issues, F/Wall rules

Timin
g
Patter
n
Life
Cycle
Phase

Possible Causes &
Testing
DIMENSI
ON

IS

BUT NOT

WHY NOT

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

Loc of
Objec
t

ANZ, USA,
UK

Asia

LAN, Proxy server
issues, F/Wall rules

Timin
g

Monday, Sept
2nd with SOB

Any time
earlier than
Sept 2nd

Java upgrade,
Netscape upgrade

Patter
n
Life
Cycle
Phase

Possible Causes &
Testing
DIMENSI
ON

IS

BUT NOT

WHY NOT

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

Loc of
Objec
t

ANZ, USA,
UK

Asia

LAN, Proxy server
issues, F/Wall rules

Timin
g

Monday, Sept
2nd with SOB

Any time
earlier than
Sept 2nd

Java upgrade,
Netscape upgrade

Patter
n

Continuous

Sporadic,
Periodic

Don’t know

Life
Cycle
Phase

Possible Causes &
Testing
DIMENSI
ON

IS

BUT NOT

WHY NOT

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

Loc of
Objec
t

ANZ, USA,
UK

Asia

LAN, Proxy server
issues, F/Wall rules

Timin
g

Monday, Sept
2nd with SOB

Any time
earlier than
Sept 2nd

Java upgrade,
Netscape upgrade

Patter
n

Continuous

Sporadic,
Periodic

Don’t know

Life
Cycle

When doing a
transaction

“x” time into
transaction

Operator error,
Code error on a
specific page

Possible Causes &
Testing
DIMENSI
ON

IS

BUT NOT

WHY NOT

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

Loc of
Objec
t

ANZ, USA,
UK

Asia

LAN, Proxy server
issues, F/Wall rules

Timin
g

Monday, Sept
2nd with SOB

Any time
earlier than
Sept 2nd

Java upgrade,
Netscape upgrade

Patter
n

Continuous

Sporadic,
Periodic

Don’t know

Life
Cycle

When doing a
transaction

“x” time into
transaction

Operator error,
Code error on a
specific page

Possible Causes &
Testing
DIMENSI
ON

IS

BUT NOT

WHY NOT

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

Loc of
Objec
t

ANZ, USA,
UK

Asia

LAN, Proxy server
issues, F/Wall rules

Timin
g

Monday, Sept
2nd with SOB

Any time
earlier than
Sept 2nd

Java upgrade,
Netscape upgrade

Patter
n

Continuous

Sporadic,
Periodic

Don’t know

Life
Cycle

When doing a
transaction

“x” time into
transaction

Operator error,
Code error on a
specific page

Possible Causes &
Testing
1. Proxy server tampered with during
the Java upgrade on the LAN
DIMENSI
ON

IS

BUT NOT

WHY NOT

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

Loc of
Objec
t

ANZ, USA,
UK

Asia

LAN, Proxy server
issues, F/Wall rules

Timin
g

Monday, Sept
2nd with SOB

Any time
earlier than
Sept 2nd

Java upgrade,
Netscape upgrade

Patter
n

Continuous

Sporadic,
Periodic

Don’t know

Life
Cycle

When doing a
transaction

“x” time into
transaction

Operator error,
Code error on a
specific page

Possible Causes &
Testing
1. Proxy server tampered with during
the Java upgrade on the LAN

2. Java upgrade caused driver
incompatibility with Fireburst website
V2.0
DIMENSI
ON

IS

BUT NOT

WHY NOT

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

Loc of
Objec
t

ANZ, USA,
UK

Asia

LAN, Proxy server
issues, F/Wall rules

Timin
g

Monday, Sept
2nd with SOB

Any time
earlier than
Sept 2nd

Java upgrade,
Netscape upgrade

Patter
n

Continuous

Sporadic,
Periodic

Don’t know

Life
Cycle

When doing a
transaction

“x” time into
transaction

Operator error,
Code error on a
specific page

Possible Causes &
Testing
1. Proxy server tampered with during
the Java upgrade on the LAN

2. Java upgrade caused driver
incompatibility with Fireburst website
V2.0

3. Netscape upgrade caused driver
incompatibility with Fireburst website
V2.0
DIMENSI
ON

IS

BUT NOT

WHY NOT

Possible Causes &
Testing

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

1. Proxy server tampered with during
the Java upgrade on the LAN

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

X

Loc of
Objec
t

ANZ, USA,
UK

Asia

LAN, Proxy server
issues, F/Wall rules

2. Java upgrade caused driver
incompatibility with Fireburst website
V2.0

Timin
g

Monday, Sept
2nd with SOB

Any time
earlier than
Sept 2nd

Java upgrade,
Netscape upgrade

Patter
n

Continuous

Sporadic,
Periodic

Don’t know

Life
Cycle

When doing a
transaction

“x” time into
transaction

Operator error,
Code error on a
specific page

3. Netscape upgrade caused driver
incompatibility with Fireburst website
V2.0
DIMENSI
ON

IS

BUT NOT

WHY NOT

Possible Causes &
Testing

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

1. Proxy server tampered with during
the Java upgrade on the LAN

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

X

Loc of
Objec
t

ANZ, USA,
UK

Asia

LAN, Proxy server
issues, F/Wall rules

2. Java upgrade caused driver
incompatibility with Fireburst website
V2.0

Timin
g

Monday, Sept
2nd with SOB

Any time
earlier than
Sept 2nd

Java upgrade,
Netscape upgrade

√

Patter
n

Continuous

Sporadic,
Periodic

Don’t know

3. Netscape upgrade caused driver
incompatibility with Fireburst website
V2.0

Life
Cycle

When doing a
transaction

“x” time into
transaction

Operator error,
Code error on a
specific page

√

X
DIMENSI
ON

IS

BUT NOT

WHY NOT

Possible Causes &
Testing

Objec
t

Fireburst V2.0
connection

E-Express,
Mango
connections

F/B upgrade from
V1 to V2, Poor
testing issue

1. Proxy server tampered with during
the Java upgrade on the LAN

Fault

dropping

Freezing, slow

Time out settings,
configuration of
drivers

X

Loc of
Objec
t

ANZ, USA,
UK

Asia

LAN, Proxy server
issues, F/Wall rules

2. Java upgrade caused driver
incompatibility with Fireburst website
V2.0

Timin
g

Monday, Sept
2nd with SOB

Any time
earlier than
Sept 2nd

Java upgrade,
Netscape upgrade

√

Patter
n

Continuous

Sporadic,
Periodic

Don’t know

3. Netscape upgrade caused driver
incompatibility with Fireburst website
V2.0

Life
Cycle

When doing a
transaction

“x” time into
transaction

Operator error,
Code error on a
specific page

√

√

√

X

A1

√

√

√

√

A1- Only if the staff in Asia did not upgrade
to Netscape
AGENDA
“Most incident
investigators ask
the wrong
questions, so do not
change your people
but change the
questions they are
asking”

• 
• 
• 
• 

Introduction
Introduce Client Situation
The Three Skills sets
The Common Process and Language

• 
• 

Technical Cause Analysis
Root Cause Components

• 
• 

Client outcomes
Questions & answers
Stair stepping…
3. Netscape upgrade caused
driver incompatibility with
Fireburst website V2.0

WHY?	
  

Installed the wrong driver

WHY?	
  

Driver Specs not correct

WHY?	
  

Don’t Know
Root Cause Analysis Components
COMPONENT

CAUSAL FACTORS

Decision Making

DM Process and Collaboration for inputs

Implementation issues

Resourcing Issues and Scope & Definition of project

Standard Operating
Procedures

Applicability of SOP, Awareness of SOP and
Documentation

Management

Management of Work and Management of Staff

Measurement

Key Performance Indicators (KPI’s) and Roles &
Responsibilities

Support

Internal Support and External Vendor support

Communications

Clarity of communications and verbal instructions

Work Environment

Task Interference and consequences of doing the task

Skills

Complexity needed and applicability of person to task

Testing Practices

Testing Procedures and Testing Requirements
Root Cause Analysis Components
COMPONENT

CAUSAL FACTORS

Decision Making

DM Process and Collaboration for inputs

Implementation issues

Resourcing Issues and Scope & Definition of project

Standard Operating
Procedures

Applicability of SOP, Awareness of SOP and
Documentation

Management

Management of Work and Management of Staff

Measurement

Key Performance Indicators (KPI’s) and Roles &
Responsibilities

Support

Internal Support and External Vendor support

Communications

Clarity of communications and verbal instructions

Work Environment

Task Interference and consequences of doing the task

Skills

Complexity needed and applicability of person to task

Testing Practices

Testing Procedures and Testing Requirements
Root Cause Analysis Components
COMPONENT

CAUSAL FACTORS

Decision Making

DM Process and Collaboration for inputs

Implementation issues

Resourcing Issues and Scope & Definition of project

Standard Operating
Procedures

Applicability of SOP, Awareness of SOP and
Documentation

Management

Management of Work and Management of Staff

Measurement

Key Performance Indicators (KPI’s) and Roles &
Responsibilities

Support

Internal Support and External Vendor support

Communications

Clarity of communications and verbal instructions

Work Environment

Task Interference and consequences of doing the task

Skills

Complexity needed and applicability of person to task

Testing Practices

Testing Procedures and Testing Requirements
Snapshot info for Solutions

Four Question Drill

Key	
  
Requirements	
  
1	
  Best	
  data	
  transfer	
  
rate	
  

• 
• 

2	
  	
  No	
  loss	
  of	
  data	
  

• 

3	
  	
  Improve	
  system	
  up-­‐
Bme	
  

• 

4	
  Improve	
  trickle	
  &	
  
purge	
  
5	
  Reduce	
  DR	
  Bme	
  
6	
  Capex	
  <	
  $2m	
  
7	
  Implement	
  <	
  3	
  mos	
  

What are the results you want to
achieve with this solution?
What are the existing problems you
would like to remove with this
solution?
What are the potential risks you
would like to avoid with this
solution?
What money and time do you have
or do you need to preserve? What
are the restrictions out of your
control?
Snapshot info for Solutions

Questions for Actions

Key	
  
Requirements	
  
1	
  Best	
  data	
  transfer	
  
rate	
  

• 

• 

2	
  	
  No	
  loss	
  of	
  data	
  

• 

3	
  	
  Improve	
  system	
  up-­‐
Bme	
  

• 

4	
  Improve	
  trickle	
  &	
  
purge	
  
5	
  Reduce	
  DR	
  Bme	
  
6	
  Capex	
  <	
  $2m	
  
7	
  Implement	
  <	
  3	
  mos	
  

• 
• 

What action can we take today and
implement tomorrow that would meet the
1st requirement? (repeat)
What action can we take today and
implement tomorrow that would meet the
2nd requirement? (repeat)
Looking at all the actions, which one(s)
would satisfy the 1st requirement best?
Which actions has got nothing to do with
the 1st requirement?
Looking at all the actions, which one(s)
would satisfy the 2st requirement best?
Repeat for each requirement…
Snapshot info for Solutions

Questions for Actions

Key	
  
Requirements	
  
1	
  Best	
  data	
  transfer	
  
rate	
  

1	
   2	
   3	
   4	
   5	
   6	
   7	
   8	
  

• 

• 

2	
  	
  No	
  loss	
  of	
  data	
  

• 

3	
  	
  Improve	
  system	
  up-­‐
Bme	
  

• 

4	
  Improve	
  trickle	
  &	
  
purge	
  
5	
  Reduce	
  DR	
  Bme	
  
6	
  Capex	
  <	
  $2m	
  
7	
  Implement	
  <	
  3	
  mos	
  

• 
• 

What action can we take today and
implement tomorrow that would meet the
1st requirement? (repeat)
What action can we take today and
implement tomorrow that would meet the
2nd requirement? (repeat)
Looking at all the actions, which one(s)
would satisfy the 1st requirement best?
Which actions has got nothing to do with
the 1st requirement?
Looking at all the actions, which one(s)
would satisfy the 2st requirement best?
Repeat for each requirement…
Snapshot info for Solutions

Questions for Actions

Key	
  
Requirements	
  
1	
  Best	
  data	
  transfer	
  
rate	
  

1	
   2	
   3	
   4	
   5	
   6	
   7	
   8	
  
3	
   3	
  

• 

• 

2	
  	
  No	
  loss	
  of	
  data	
  

• 

3	
  	
  Improve	
  system	
  up-­‐
Bme	
  

• 

4	
  Improve	
  trickle	
  &	
  
purge	
  
5	
  Reduce	
  DR	
  Bme	
  
6	
  Capex	
  <	
  $2m	
  
7	
  Implement	
  <	
  3	
  mos	
  

• 
• 

What action can we take today and
implement tomorrow that would meet the
1st requirement? (repeat)
What action can we take today and
implement tomorrow that would meet the
2nd requirement? (repeat)
Looking at all the actions, which one(s)
would satisfy the 1st requirement best?
Which actions has got nothing to do with
the 1st requirement?
Looking at all the actions, which one(s)
would satisfy the 2st requirement best?
Repeat for each requirement…
Snapshot info for Solutions

Questions for Actions

Key	
  
Requirements	
  
1	
  Best	
  data	
  transfer	
  
rate	
  

1	
   2	
   3	
   4	
   5	
   6	
   7	
   8	
  
3	
   3	
   0	
  

0	
   0	
   0	
   0	
  

• 

• 

2	
  	
  No	
  loss	
  of	
  data	
  

• 

3	
  	
  Improve	
  system	
  up-­‐
Bme	
  

• 

4	
  Improve	
  trickle	
  &	
  
purge	
  
5	
  Reduce	
  DR	
  Bme	
  
6	
  Capex	
  <	
  $2m	
  
7	
  Implement	
  <	
  3	
  mos	
  

• 
• 

What action can we take today and
implement tomorrow that would meet the
1st requirement? (repeat)
What action can we take today and
implement tomorrow that would meet the
2nd requirement? (repeat)
Looking at all the actions, which one(s)
would satisfy the 1st requirement best?
Which actions has got nothing to do with
the 1st requirement?
Looking at all the actions, which one(s)
would satisfy the 2st requirement best?
Repeat for each requirement…
Snapshot info for Solutions

Questions for Actions

Key	
  
Requirements	
  
1	
  Best	
  data	
  transfer	
  
rate	
  

1	
   2	
   3	
   4	
   5	
   6	
   7	
   8	
  
3	
   3	
   0	
   1	
   0	
   0	
   0	
   0	
  

• 

• 

2	
  	
  No	
  loss	
  of	
  data	
  

• 

3	
  	
  Improve	
  system	
  up-­‐
Bme	
  

• 

4	
  Improve	
  trickle	
  &	
  
purge	
  
5	
  Reduce	
  DR	
  Bme	
  
6	
  Capex	
  <	
  $2m	
  
7	
  Implement	
  <	
  3	
  mos	
  

• 
• 

What action can we take today and
implement tomorrow that would meet the
1st requirement? (repeat)
What action can we take today and
implement tomorrow that would meet the
2nd requirement? (repeat)
Looking at all the actions, which one(s)
would satisfy the 1st requirement best?
Which actions has got nothing to do with
the 1st requirement?
Looking at all the actions, which one(s)
would satisfy the 2st requirement best?
Repeat for each requirement…
Snapshot info for Solutions

Questions for Actions

Key	
  
Requirements	
  

1	
   2	
   3	
   4	
   5	
   6	
   7	
   8	
  

• 

• 

1	
  Best	
  data	
  transfer	
  
rate	
  

3	
   3	
   0	
   1	
   0	
   0	
   0	
   0	
  

2	
  	
  No	
  loss	
  of	
  data	
  

0	
   3	
   3	
   0	
   0	
   1	
   2	
   2	
  

• 

3	
  	
  Improve	
  system	
  up-­‐
Bme	
  

1	
   2	
   1	
   0	
   3	
   1	
   2	
   1	
  

• 

4	
  Improve	
  trickle	
  &	
  
purge	
  

2	
   2	
   3	
   1	
   0	
   0	
   0	
   0	
  

5	
  Reduce	
  DR	
  Bme	
  

1	
   1	
   3	
   2	
   1	
   1	
   3	
   1	
  

6	
  Capex	
  <	
  $2m	
  

3	
   1	
   2	
   2	
   1	
   0	
   3	
   1	
  

7	
  Implement	
  <	
  3	
  mos	
  

0	
   3	
   0	
   0	
   0	
   1	
   3	
   3	
  

• 
• 

What action can we take today and
implement tomorrow that would meet the
1st requirement? (repeat)
What action can we take today and
implement tomorrow that would meet the
2nd requirement? (repeat)
Looking at all the actions, which one(s)
would satisfy the 1st requirement best?
Which actions has got nothing to do with
the 1st requirement?
Looking at all the actions, which one(s)
would satisfy the 2st requirement best?
Repeat for each requirement…
Snapshot info for Solutions

Develop the new solution

Key	
  
Requirements	
  

1	
   2	
   3	
   4	
   5	
   6	
   7	
   8	
  

1	
  Best	
  data	
  transfer	
  
rate	
  

3	
   3	
   0	
   1	
   0	
   0	
   0	
   0	
  

2	
  	
  No	
  loss	
  of	
  data	
  

0	
   3	
   3	
   0	
   0	
   1	
   2	
   2	
  

3	
  	
  Improve	
  system	
  up-­‐
Bme	
  

1	
   2	
   1	
   0	
   3	
   1	
   2	
   1	
  

4	
  Improve	
  trickle	
  &	
  
purge	
  

2	
   2	
   3	
   1	
   0	
   0	
   0	
   0	
  

5	
  Reduce	
  DR	
  Bme	
  

1	
   1	
   3	
   2	
   1	
   1	
   3	
   1	
  

6	
  Capex	
  <	
  $2m	
  

3	
   1	
   2	
   2	
   1	
   0	
   3	
   1	
  

7	
  Implement	
  <	
  3	
  mos	
  

0	
   3	
   0	
   0	
   0	
   1	
   3	
   3	
  

• 

Circle the best performing areas to
give you a visual impact of best
performing actions.
Snapshot info for Solutions

Develop the new solution

• 

Key	
  
Requirements	
  

1	
   2	
   3	
   4	
   5	
   6	
   7	
   8	
  

1	
  Best	
  data	
  transfer	
  
rate	
  

3	
   3	
   0	
   1	
   0	
   0	
   0	
   0	
   • 

2	
  	
  No	
  loss	
  of	
  data	
  

0	
   3	
   3	
   0	
   0	
   1	
   2	
   2	
  

3	
  	
  Improve	
  system	
  up-­‐
Bme	
  

1	
   2	
   1	
   0	
   3	
   1	
   2	
   1	
   • 

4	
  Improve	
  trickle	
  &	
  
purge	
  

2	
   2	
   3	
   1	
   0	
   0	
   0	
   0	
  

5	
  Reduce	
  DR	
  Bme	
  

1	
   1	
   3	
   2	
   1	
   1	
   3	
   1	
  

6	
  Capex	
  <	
  $2m	
  

3	
   1	
   2	
   2	
   1	
   0	
   3	
   1	
  

7	
  Implement	
  <	
  3	
  mos	
  

0	
   3	
   0	
   0	
   0	
   1	
   3	
   3	
  

Circle the best performing areas to
give you a visual impact of best
performing actions.
ASK: Which combination of actions
would give you at least one [3] for
each requirement? Look for at least
3-4 actions to combine
Lastly, which action(s) do we have
to add to the mix to make the
suggested solution even more
effective?
Snapshot info for Solutions

The	
  Solu.on!	
  

Key	
  
Requirements	
  

1	
   2	
   3	
   4	
   5	
   6	
   7	
   8	
  

1	
  Best	
  data	
  transfer	
  
rate	
  

3	
   3	
   0	
   1	
   0	
   0	
   0	
   0	
  

2	
  	
  No	
  loss	
  of	
  data	
  

0	
   3	
   3	
   0	
   0	
   1	
   2	
   2	
  

3	
  	
  Improve	
  system	
  up-­‐
Bme	
  

1	
   2	
   1	
   0	
   3	
   1	
   2	
   1	
  

4	
  Improve	
  trickle	
  &	
  
purge	
  

2	
   2	
   3	
   1	
   0	
   0	
   0	
   0	
  

5	
  Reduce	
  DR	
  Bme	
  

1	
   1	
   3	
   2	
   1	
   1	
   3	
   1	
  

6	
  Capex	
  <	
  $2m	
  

3	
   1	
   2	
   2	
   1	
   0	
   3	
   1	
  

7	
  Implement	
  <	
  3	
  mos	
  

0	
   3	
   0	
   0	
   0	
   1	
   3	
   3	
  

	
  
• 

• 

• 

Which	
  combinaBon	
  of	
  acBons	
  makes	
  
the	
  best	
  sense	
  and	
  would	
  provide	
  the	
  
best	
  chance	
  of	
  success?	
  
Check	
  whether	
  your	
  suggested	
  
soluBon	
  would	
  saBsfy	
  all	
  the	
  
requirements.	
  Also	
  check	
  impact	
  on	
  
implementaBon	
  costs	
  
How	
  would	
  you	
  suggest	
  we	
  implement	
  
these	
  acBons?	
  
AGENDA
“Most incident
investigators ask
the wrong
questions, so do not
change your people
but change the
questions they are
asking”

• 
• 
• 
• 

Introduction
Introduce Client Situation
The Three Skills sets
The Common Process and Language

• 
• 

Technical Cause Analysis
Root Cause Components

• 
• 

Client outcomes
Questions & answers
Application Performance results
Our client’s
systems
availability went
from 76% at the
end of 2009 to
88% end 2010 to
eventually 95% at
the end of 2012 –
A gain of 19%

100	
  
90	
  
80	
  
70	
  
Mean-­‐Bme-­‐to-­‐repair	
  

60	
  

Improvement	
  m-­‐t-­‐t-­‐r	
  

50	
  

Availability	
  
40	
  
30	
  
20	
  
10	
  
0	
  

2009	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  2010	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  2012	
  
Improvement in escalations
In our client’s case
the P2 to P1
escalations dropped
by 38%

90	
  
80	
  
70	
  
60	
  

Recurring incidents
dropped by 21%

50	
  
40	
  

P3 to P2 escalations
dropped by 19%

30	
  
20	
  
10	
  
0	
  

Sev	
  3	
  to	
  Sev	
  2	
  

Sev2	
  to	
  Sev	
  1	
  

Recurring	
  
problems	
  

Vendor	
  
Interven:ons	
  
Lessons learned..
• 
• 
• 
• 
• 
• 
• 

Most of the recurring incidents and problems are caused by “out of date
procedures” and lack of proper documentation
TCA is a “mental orientation” which people have to get trained in – “does not
come with experience”
IT professionals need a “thinking approach” that could be applied in most
situations
Rules of Engagement to become a standing order
Encourage use in all incident investigation meetings – ask for the
paperwork/evidence
Sponsors continuous TCA/RCA training
Regular email communications to publish successes
Questions & Answers
I thank you for your time!

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HDI Capital Area January 15 2014

  • 1. Welcome!   Updates  from  HDI  Capital  Area   and  HDI  Corporate     2/5/14   January  15,  2014     ©2013  HDI.  All  rights  reserved.  
  • 2. New!  HDI  Cer:fica:on   •  HDI  announces  a  new  cerBficaBon:              HDI  Problem  Management  Professional         •  The  first  offering  will  be  at  HDI  2014  in   Orlando.     •  Learn  more  at  www.ThinkHDI.com/PM      
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  • 5. New!  Content  to  Share!   “Show  Me  the  Value:  Support’s  Mandate”  –  Roy  Atkinson   SupportWorld:  “Moments  of  Truth:  The  Future  of  the  Customer  Experience”  –   Charles  Araujo   Most  Recent  Blog:  “ Are  You  Keeping  the  Lights  On,  or  Are  You  Driving  Change?”  –  Rob  Stroud   #HDIStatToday:   15%  of  technical  support  Bckets  are  related  to  supporBng  mobile   devices.       Research  Brief:  “Mobile  Device  Support  and  BYOD:  Where  Are  We  Now?  “   Current  Survey:  4th  annual  Desktop  Support  PracBces  &  Salary  Survey       Webcast:  “Managing  Change  and  Technology  MigraBons”  –  Peter  Jurhs   Coming  up!    SupportWorld  App  debuts  in  January  !  
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  • 17. Call  for  Capital  Area  Board  Nomina:ons     •  NominaBons  due  by  January  27     –  VP  Programs   –  VP  Membership   –  VP  Finance   –  VP  Special  Programs  &  Vendor  Liaison    
  • 18. Next  Mee:ng   •  Who  Moved  My  Service  Desk?   February  19,  12:00  pm  -­‐  2:00  pm   Marc  Fey,  Cherwell  Sofware   •  We  typically  meet  the  3rd  Wednesday  of  the   month  and  most  meeBngs  are  free   •  Visit  www.hdicapitalarea.com  to  register    
  • 19. Today’s  Speaker   •  Dr.  Mah  Fourie  
  • 20. FINDING THE “ROOT” IN ROOT CAUSE ANALYSIS – A CLIENT CASE MATT FOURIE THINKING DIMENSIONS
  • 21. Some of our recent clients... Barclays IT Macquarie ITG Unisys Woolworths IT SGX IT SITA Global BT Financial McDonalds IT Queensland Police IT DBS IT Lockheed Martin Space Systems •  Thinking Dimensions International - operating KEPNERandFOURIE RCA company initiatives for the last 25 years •  Specializes in RCA Methodology for IT Incidents, Problems and Projects
  • 22. AGENDA “Most incident investigators ask the wrong questions, so do not change your people but change the questions they are asking” •  •  •  •  Introduction Introduce Client Situation The Three Skills sets The Common Process and Language •  •  Technical Cause Analysis Root Cause Components •  •  Client outcomes Questions & answers
  • 23. Investigation Info “It takes a company without a formal and effective Root Cause Analysis culture up to 23 days to repair service incidents” Aberdeen Group – Boston 2010
  • 24. AGENDA “Most incident investigators ask the wrong questions, so do not change your people but change the questions they are asking” •  •  •  •  Introduction Introduce Client Situation The Three Skills sets The Common Process and Language •  •  Technical Cause Analysis Root Cause Components •  •  Client outcomes Questions & answers
  • 25. Client Case - PM Improvement International Investment Bank’s IT PM Division 2009-2012 •  •  •  •  •  Lack of Stakeholder commitment Poor management of information Working with poor quality information Poor problem investigation support Not really solving problems permanently
  • 26. Actions taken… •  For P1 & 2 Incidents a PM was assigned immediately •  All Incident & Problem Management Staff trained in some common process •  Embedded the tools and templates into existing process to make handover seamless •  Used in-house facilitators to lead PM teams in a very strong and decisive way
  • 27. AGENDA “Most incident investigators ask the wrong questions, so do not change your people but change the questions they are asking” •  •  •  •  Introduction Introduce Client Situation The Three Skills sets The Common Process and Language •  •  Technical Cause Analysis Root Cause Components •  •  Client outcomes Questions & answers
  • 28. PAST   NOW   FUTURE   STANDARD TECHNICAL  CAUSE   ANALYSIS   INCIDENT  RESTORATION   ROOT  CAUSE  ANALYSIS  
  • 29. AGENDA “Most incident investigators ask the wrong questions, so do not change your people but change the questions they are asking” •  •  •  •  Introduction Introduce Client Situation The Three Skills sets The Common Process and Language •  •  Technical Cause Analysis Root Cause Components •  •  Client outcomes Questions & answers
  • 30. Common process •  Step  1:    IdenBfy  Problem    SituaBon   •  Step  2:    Gather  Incident                InformaBon   •  Step  3:    Analyse  Incident    InformaBon   Step  4:    Determine  Conclusion   Everybody uses the same process for finding causes and solutions The process determines which questions to ask at each step for each type of incident investigation approach Designed for minimalistic information combined with a good focus to provide quick answers
  • 31. AGENDA “Most incident investigators ask the wrong questions, so do not change your people but change the questions they are asking” •  •  •  •  Introduction Introduce Client Situation The Three Skills sets The Common Process and Language •  •  Technical Cause Analysis Root Cause Components •  •  Client outcomes Questions & answers
  • 32. Extreme Focus With “Specificity” Object   Servers   Fault   Not  communicaBng   Data  not  transferred     Sent  but  not  received   by  receiving  servers   Data  for  Large  Outlets   Not  received   Sales  turnover   numbers  for  Large   Outlets   Not  received   Specificity Rules • One object one fault • Single-minded & simplistic • Highly focused • Must find the correct entry point • Ask a question – expect an answer
  • 33. Extreme Focus With “Specificity” Object Murex Chip Fault Produces latency Transactions queuing up TX’s taking longer than 100 milliseconds Transactions Takes longer to process “Futures” transactions Takes longer to process Specificity Rules • One object one fault • Single-minded & simplistic • Highly focused • Must find the correct entry point • Ask a question – expect an answer
  • 34. Thinking more specifically… Incident Statement Technical Cause Root Cause Internet Banking Degrading New Integrative testing browser not done properly configurati on issue Encrypted “hello” message ‘Beta’ Policy Certificate requirements for used “production”
  • 35. Thinking more specifically… Incident  Statement   Technical  Cause   G-­‐Force   System   Freezing   G-­‐Force  SQL   DB  thread   count   exceeding   Root  Cause   High  volume   Too  many   users  allowed   access   G-­‐Force   Vendor   program  not   implemented   closing  out   an  untested   threads   program  
  • 36. Crea:ng  Intelligence   DATA   IS   INFORMATI ON   BUT  NOT   KNOWLEDGE   WHY  NOT   APAC   users   Freezing   Different   rouBng   SSL   handshake   USA,  UK   Volume?   Started   Oct  1   Before   ADSL  lines   Awer  4pm     New   passwords   Internet   Banking   Slow   ConBnuou Intranet   Banking   Unexpected Outcomes • “BUT NOT” clarifies the facts • Creates a curious “contrast” • Looking at answers at a “granular level” • Stimulates deductive reasoning
  • 37. Example of templates with questions
  • 38. “Minimalistic principle”.. •  Only need to analyse the information that would be relevant to the incident •  Worked questions within a customised “factor analysis” framework •  Get a quick factual “snapshot” of the characteristics of the incident and then use SME experience and gut feel to explain the snapshot •  Test SME inputs against logic of snapshot “Too much information can cause confusion. The key is to get all the relevant information only and that is normally substantially less than gathering all the Information.” Innovation – the FreeZone thinking experience. by Kepner & Fourie
  • 39. Snapshot info for causes IS   BUT   NOT   WHY   NOT   OBJECT – What object and which other object(s) not? FAULT – What fault and which other typical faults not? OBJECT   USERS – Who has the problem and who does not? FAULT   WHERE – Where are these users and where could they have been but are not? USERS   WHERE   TIMING   PATTER N   CYCLE   TIMING – When did it happen first time and when not? PATTERN – What is the pattern of faults and what could it have been but is not? CYCLE – In which cycle does the problem occur and in which cycle does it not occur?
  • 40. CauseWise sample   DIMENSIO N   Object   Fault   Loc  of   Object   Timing   Pahern   Life   Cycle   Phase   of   Work   IS   BUT  NOT   WHY  NOT   Possible  Causes  &  Tes:ng  
  • 41. CauseWise sample   DIMENSIO N   Object   Fault   Loc  of   Object   Timing   Pahern   Life   Cycle   Phase   of   Work   IS   Fireburst  V2.0   connecBon     BUT  NOT   WHY  NOT   Possible  Causes  &  Tes:ng  
  • 42.   DIMENSIO N   Object   Fault   Loc  of   Object   Timing   Pahern   Life   Cycle   Phase   of   Work   IS   Fireburst  V2.0   connecBon     BUT  NOT   E-­‐Express,   Mango   connecBons   WHY  NOT   Possible  Causes  &  Tes:ng  
  • 43.   DIMENSIO N   Object   Fault   Loc  of   Object   Timing   Pahern   Life   Cycle   Phase   of   Work   IS   Fireburst  V2.0   connecBon     BUT  NOT   E-­‐Express,   Mango   connecBons   WHY  NOT   F/B  upgrade  from  V1   to  V2,  Poor  tesBng   issue   Possible  Causes  &  Tes:ng  
  • 44. DIMENSI ON IS BUT NOT WHY NOT Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue Fault dropping Freezing, slow Time out settings, configuration of drivers Loc of Objec t Timin g Patter n Life Cycle Phase Possible Causes & Testing
  • 45. DIMENSI ON IS BUT NOT WHY NOT Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue Fault dropping Freezing, slow Time out settings, configuration of drivers Loc of Objec t ANZ, USA, UK Asia LAN, Proxy server issues, F/Wall rules Timin g Patter n Life Cycle Phase Possible Causes & Testing
  • 46. DIMENSI ON IS BUT NOT WHY NOT Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue Fault dropping Freezing, slow Time out settings, configuration of drivers Loc of Objec t ANZ, USA, UK Asia LAN, Proxy server issues, F/Wall rules Timin g Monday, Sept 2nd with SOB Any time earlier than Sept 2nd Java upgrade, Netscape upgrade Patter n Life Cycle Phase Possible Causes & Testing
  • 47. DIMENSI ON IS BUT NOT WHY NOT Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue Fault dropping Freezing, slow Time out settings, configuration of drivers Loc of Objec t ANZ, USA, UK Asia LAN, Proxy server issues, F/Wall rules Timin g Monday, Sept 2nd with SOB Any time earlier than Sept 2nd Java upgrade, Netscape upgrade Patter n Continuous Sporadic, Periodic Don’t know Life Cycle Phase Possible Causes & Testing
  • 48. DIMENSI ON IS BUT NOT WHY NOT Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue Fault dropping Freezing, slow Time out settings, configuration of drivers Loc of Objec t ANZ, USA, UK Asia LAN, Proxy server issues, F/Wall rules Timin g Monday, Sept 2nd with SOB Any time earlier than Sept 2nd Java upgrade, Netscape upgrade Patter n Continuous Sporadic, Periodic Don’t know Life Cycle When doing a transaction “x” time into transaction Operator error, Code error on a specific page Possible Causes & Testing
  • 49. DIMENSI ON IS BUT NOT WHY NOT Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue Fault dropping Freezing, slow Time out settings, configuration of drivers Loc of Objec t ANZ, USA, UK Asia LAN, Proxy server issues, F/Wall rules Timin g Monday, Sept 2nd with SOB Any time earlier than Sept 2nd Java upgrade, Netscape upgrade Patter n Continuous Sporadic, Periodic Don’t know Life Cycle When doing a transaction “x” time into transaction Operator error, Code error on a specific page Possible Causes & Testing
  • 50. DIMENSI ON IS BUT NOT WHY NOT Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue Fault dropping Freezing, slow Time out settings, configuration of drivers Loc of Objec t ANZ, USA, UK Asia LAN, Proxy server issues, F/Wall rules Timin g Monday, Sept 2nd with SOB Any time earlier than Sept 2nd Java upgrade, Netscape upgrade Patter n Continuous Sporadic, Periodic Don’t know Life Cycle When doing a transaction “x” time into transaction Operator error, Code error on a specific page Possible Causes & Testing 1. Proxy server tampered with during the Java upgrade on the LAN
  • 51. DIMENSI ON IS BUT NOT WHY NOT Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue Fault dropping Freezing, slow Time out settings, configuration of drivers Loc of Objec t ANZ, USA, UK Asia LAN, Proxy server issues, F/Wall rules Timin g Monday, Sept 2nd with SOB Any time earlier than Sept 2nd Java upgrade, Netscape upgrade Patter n Continuous Sporadic, Periodic Don’t know Life Cycle When doing a transaction “x” time into transaction Operator error, Code error on a specific page Possible Causes & Testing 1. Proxy server tampered with during the Java upgrade on the LAN 2. Java upgrade caused driver incompatibility with Fireburst website V2.0
  • 52. DIMENSI ON IS BUT NOT WHY NOT Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue Fault dropping Freezing, slow Time out settings, configuration of drivers Loc of Objec t ANZ, USA, UK Asia LAN, Proxy server issues, F/Wall rules Timin g Monday, Sept 2nd with SOB Any time earlier than Sept 2nd Java upgrade, Netscape upgrade Patter n Continuous Sporadic, Periodic Don’t know Life Cycle When doing a transaction “x” time into transaction Operator error, Code error on a specific page Possible Causes & Testing 1. Proxy server tampered with during the Java upgrade on the LAN 2. Java upgrade caused driver incompatibility with Fireburst website V2.0 3. Netscape upgrade caused driver incompatibility with Fireburst website V2.0
  • 53. DIMENSI ON IS BUT NOT WHY NOT Possible Causes & Testing Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue 1. Proxy server tampered with during the Java upgrade on the LAN Fault dropping Freezing, slow Time out settings, configuration of drivers X Loc of Objec t ANZ, USA, UK Asia LAN, Proxy server issues, F/Wall rules 2. Java upgrade caused driver incompatibility with Fireburst website V2.0 Timin g Monday, Sept 2nd with SOB Any time earlier than Sept 2nd Java upgrade, Netscape upgrade Patter n Continuous Sporadic, Periodic Don’t know Life Cycle When doing a transaction “x” time into transaction Operator error, Code error on a specific page 3. Netscape upgrade caused driver incompatibility with Fireburst website V2.0
  • 54. DIMENSI ON IS BUT NOT WHY NOT Possible Causes & Testing Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue 1. Proxy server tampered with during the Java upgrade on the LAN Fault dropping Freezing, slow Time out settings, configuration of drivers X Loc of Objec t ANZ, USA, UK Asia LAN, Proxy server issues, F/Wall rules 2. Java upgrade caused driver incompatibility with Fireburst website V2.0 Timin g Monday, Sept 2nd with SOB Any time earlier than Sept 2nd Java upgrade, Netscape upgrade √ Patter n Continuous Sporadic, Periodic Don’t know 3. Netscape upgrade caused driver incompatibility with Fireburst website V2.0 Life Cycle When doing a transaction “x” time into transaction Operator error, Code error on a specific page √ X
  • 55. DIMENSI ON IS BUT NOT WHY NOT Possible Causes & Testing Objec t Fireburst V2.0 connection E-Express, Mango connections F/B upgrade from V1 to V2, Poor testing issue 1. Proxy server tampered with during the Java upgrade on the LAN Fault dropping Freezing, slow Time out settings, configuration of drivers X Loc of Objec t ANZ, USA, UK Asia LAN, Proxy server issues, F/Wall rules 2. Java upgrade caused driver incompatibility with Fireburst website V2.0 Timin g Monday, Sept 2nd with SOB Any time earlier than Sept 2nd Java upgrade, Netscape upgrade √ Patter n Continuous Sporadic, Periodic Don’t know 3. Netscape upgrade caused driver incompatibility with Fireburst website V2.0 Life Cycle When doing a transaction “x” time into transaction Operator error, Code error on a specific page √ √ √ X A1 √ √ √ √ A1- Only if the staff in Asia did not upgrade to Netscape
  • 56. AGENDA “Most incident investigators ask the wrong questions, so do not change your people but change the questions they are asking” •  •  •  •  Introduction Introduce Client Situation The Three Skills sets The Common Process and Language •  •  Technical Cause Analysis Root Cause Components •  •  Client outcomes Questions & answers
  • 57. Stair stepping… 3. Netscape upgrade caused driver incompatibility with Fireburst website V2.0 WHY?   Installed the wrong driver WHY?   Driver Specs not correct WHY?   Don’t Know
  • 58. Root Cause Analysis Components COMPONENT CAUSAL FACTORS Decision Making DM Process and Collaboration for inputs Implementation issues Resourcing Issues and Scope & Definition of project Standard Operating Procedures Applicability of SOP, Awareness of SOP and Documentation Management Management of Work and Management of Staff Measurement Key Performance Indicators (KPI’s) and Roles & Responsibilities Support Internal Support and External Vendor support Communications Clarity of communications and verbal instructions Work Environment Task Interference and consequences of doing the task Skills Complexity needed and applicability of person to task Testing Practices Testing Procedures and Testing Requirements
  • 59. Root Cause Analysis Components COMPONENT CAUSAL FACTORS Decision Making DM Process and Collaboration for inputs Implementation issues Resourcing Issues and Scope & Definition of project Standard Operating Procedures Applicability of SOP, Awareness of SOP and Documentation Management Management of Work and Management of Staff Measurement Key Performance Indicators (KPI’s) and Roles & Responsibilities Support Internal Support and External Vendor support Communications Clarity of communications and verbal instructions Work Environment Task Interference and consequences of doing the task Skills Complexity needed and applicability of person to task Testing Practices Testing Procedures and Testing Requirements
  • 60. Root Cause Analysis Components COMPONENT CAUSAL FACTORS Decision Making DM Process and Collaboration for inputs Implementation issues Resourcing Issues and Scope & Definition of project Standard Operating Procedures Applicability of SOP, Awareness of SOP and Documentation Management Management of Work and Management of Staff Measurement Key Performance Indicators (KPI’s) and Roles & Responsibilities Support Internal Support and External Vendor support Communications Clarity of communications and verbal instructions Work Environment Task Interference and consequences of doing the task Skills Complexity needed and applicability of person to task Testing Practices Testing Procedures and Testing Requirements
  • 61. Snapshot info for Solutions Four Question Drill Key   Requirements   1  Best  data  transfer   rate   •  •  2    No  loss  of  data   •  3    Improve  system  up-­‐ Bme   •  4  Improve  trickle  &   purge   5  Reduce  DR  Bme   6  Capex  <  $2m   7  Implement  <  3  mos   What are the results you want to achieve with this solution? What are the existing problems you would like to remove with this solution? What are the potential risks you would like to avoid with this solution? What money and time do you have or do you need to preserve? What are the restrictions out of your control?
  • 62. Snapshot info for Solutions Questions for Actions Key   Requirements   1  Best  data  transfer   rate   •  •  2    No  loss  of  data   •  3    Improve  system  up-­‐ Bme   •  4  Improve  trickle  &   purge   5  Reduce  DR  Bme   6  Capex  <  $2m   7  Implement  <  3  mos   •  •  What action can we take today and implement tomorrow that would meet the 1st requirement? (repeat) What action can we take today and implement tomorrow that would meet the 2nd requirement? (repeat) Looking at all the actions, which one(s) would satisfy the 1st requirement best? Which actions has got nothing to do with the 1st requirement? Looking at all the actions, which one(s) would satisfy the 2st requirement best? Repeat for each requirement…
  • 63. Snapshot info for Solutions Questions for Actions Key   Requirements   1  Best  data  transfer   rate   1   2   3   4   5   6   7   8   •  •  2    No  loss  of  data   •  3    Improve  system  up-­‐ Bme   •  4  Improve  trickle  &   purge   5  Reduce  DR  Bme   6  Capex  <  $2m   7  Implement  <  3  mos   •  •  What action can we take today and implement tomorrow that would meet the 1st requirement? (repeat) What action can we take today and implement tomorrow that would meet the 2nd requirement? (repeat) Looking at all the actions, which one(s) would satisfy the 1st requirement best? Which actions has got nothing to do with the 1st requirement? Looking at all the actions, which one(s) would satisfy the 2st requirement best? Repeat for each requirement…
  • 64. Snapshot info for Solutions Questions for Actions Key   Requirements   1  Best  data  transfer   rate   1   2   3   4   5   6   7   8   3   3   •  •  2    No  loss  of  data   •  3    Improve  system  up-­‐ Bme   •  4  Improve  trickle  &   purge   5  Reduce  DR  Bme   6  Capex  <  $2m   7  Implement  <  3  mos   •  •  What action can we take today and implement tomorrow that would meet the 1st requirement? (repeat) What action can we take today and implement tomorrow that would meet the 2nd requirement? (repeat) Looking at all the actions, which one(s) would satisfy the 1st requirement best? Which actions has got nothing to do with the 1st requirement? Looking at all the actions, which one(s) would satisfy the 2st requirement best? Repeat for each requirement…
  • 65. Snapshot info for Solutions Questions for Actions Key   Requirements   1  Best  data  transfer   rate   1   2   3   4   5   6   7   8   3   3   0   0   0   0   0   •  •  2    No  loss  of  data   •  3    Improve  system  up-­‐ Bme   •  4  Improve  trickle  &   purge   5  Reduce  DR  Bme   6  Capex  <  $2m   7  Implement  <  3  mos   •  •  What action can we take today and implement tomorrow that would meet the 1st requirement? (repeat) What action can we take today and implement tomorrow that would meet the 2nd requirement? (repeat) Looking at all the actions, which one(s) would satisfy the 1st requirement best? Which actions has got nothing to do with the 1st requirement? Looking at all the actions, which one(s) would satisfy the 2st requirement best? Repeat for each requirement…
  • 66. Snapshot info for Solutions Questions for Actions Key   Requirements   1  Best  data  transfer   rate   1   2   3   4   5   6   7   8   3   3   0   1   0   0   0   0   •  •  2    No  loss  of  data   •  3    Improve  system  up-­‐ Bme   •  4  Improve  trickle  &   purge   5  Reduce  DR  Bme   6  Capex  <  $2m   7  Implement  <  3  mos   •  •  What action can we take today and implement tomorrow that would meet the 1st requirement? (repeat) What action can we take today and implement tomorrow that would meet the 2nd requirement? (repeat) Looking at all the actions, which one(s) would satisfy the 1st requirement best? Which actions has got nothing to do with the 1st requirement? Looking at all the actions, which one(s) would satisfy the 2st requirement best? Repeat for each requirement…
  • 67. Snapshot info for Solutions Questions for Actions Key   Requirements   1   2   3   4   5   6   7   8   •  •  1  Best  data  transfer   rate   3   3   0   1   0   0   0   0   2    No  loss  of  data   0   3   3   0   0   1   2   2   •  3    Improve  system  up-­‐ Bme   1   2   1   0   3   1   2   1   •  4  Improve  trickle  &   purge   2   2   3   1   0   0   0   0   5  Reduce  DR  Bme   1   1   3   2   1   1   3   1   6  Capex  <  $2m   3   1   2   2   1   0   3   1   7  Implement  <  3  mos   0   3   0   0   0   1   3   3   •  •  What action can we take today and implement tomorrow that would meet the 1st requirement? (repeat) What action can we take today and implement tomorrow that would meet the 2nd requirement? (repeat) Looking at all the actions, which one(s) would satisfy the 1st requirement best? Which actions has got nothing to do with the 1st requirement? Looking at all the actions, which one(s) would satisfy the 2st requirement best? Repeat for each requirement…
  • 68. Snapshot info for Solutions Develop the new solution Key   Requirements   1   2   3   4   5   6   7   8   1  Best  data  transfer   rate   3   3   0   1   0   0   0   0   2    No  loss  of  data   0   3   3   0   0   1   2   2   3    Improve  system  up-­‐ Bme   1   2   1   0   3   1   2   1   4  Improve  trickle  &   purge   2   2   3   1   0   0   0   0   5  Reduce  DR  Bme   1   1   3   2   1   1   3   1   6  Capex  <  $2m   3   1   2   2   1   0   3   1   7  Implement  <  3  mos   0   3   0   0   0   1   3   3   •  Circle the best performing areas to give you a visual impact of best performing actions.
  • 69. Snapshot info for Solutions Develop the new solution •  Key   Requirements   1   2   3   4   5   6   7   8   1  Best  data  transfer   rate   3   3   0   1   0   0   0   0   •  2    No  loss  of  data   0   3   3   0   0   1   2   2   3    Improve  system  up-­‐ Bme   1   2   1   0   3   1   2   1   •  4  Improve  trickle  &   purge   2   2   3   1   0   0   0   0   5  Reduce  DR  Bme   1   1   3   2   1   1   3   1   6  Capex  <  $2m   3   1   2   2   1   0   3   1   7  Implement  <  3  mos   0   3   0   0   0   1   3   3   Circle the best performing areas to give you a visual impact of best performing actions. ASK: Which combination of actions would give you at least one [3] for each requirement? Look for at least 3-4 actions to combine Lastly, which action(s) do we have to add to the mix to make the suggested solution even more effective?
  • 70. Snapshot info for Solutions The  Solu.on!   Key   Requirements   1   2   3   4   5   6   7   8   1  Best  data  transfer   rate   3   3   0   1   0   0   0   0   2    No  loss  of  data   0   3   3   0   0   1   2   2   3    Improve  system  up-­‐ Bme   1   2   1   0   3   1   2   1   4  Improve  trickle  &   purge   2   2   3   1   0   0   0   0   5  Reduce  DR  Bme   1   1   3   2   1   1   3   1   6  Capex  <  $2m   3   1   2   2   1   0   3   1   7  Implement  <  3  mos   0   3   0   0   0   1   3   3     •  •  •  Which  combinaBon  of  acBons  makes   the  best  sense  and  would  provide  the   best  chance  of  success?   Check  whether  your  suggested   soluBon  would  saBsfy  all  the   requirements.  Also  check  impact  on   implementaBon  costs   How  would  you  suggest  we  implement   these  acBons?  
  • 71. AGENDA “Most incident investigators ask the wrong questions, so do not change your people but change the questions they are asking” •  •  •  •  Introduction Introduce Client Situation The Three Skills sets The Common Process and Language •  •  Technical Cause Analysis Root Cause Components •  •  Client outcomes Questions & answers
  • 72. Application Performance results Our client’s systems availability went from 76% at the end of 2009 to 88% end 2010 to eventually 95% at the end of 2012 – A gain of 19% 100   90   80   70   Mean-­‐Bme-­‐to-­‐repair   60   Improvement  m-­‐t-­‐t-­‐r   50   Availability   40   30   20   10   0   2009                    2010                      2012  
  • 73. Improvement in escalations In our client’s case the P2 to P1 escalations dropped by 38% 90   80   70   60   Recurring incidents dropped by 21% 50   40   P3 to P2 escalations dropped by 19% 30   20   10   0   Sev  3  to  Sev  2   Sev2  to  Sev  1   Recurring   problems   Vendor   Interven:ons  
  • 74. Lessons learned.. •  •  •  •  •  •  •  Most of the recurring incidents and problems are caused by “out of date procedures” and lack of proper documentation TCA is a “mental orientation” which people have to get trained in – “does not come with experience” IT professionals need a “thinking approach” that could be applied in most situations Rules of Engagement to become a standing order Encourage use in all incident investigation meetings – ask for the paperwork/evidence Sponsors continuous TCA/RCA training Regular email communications to publish successes
  • 75. Questions & Answers I thank you for your time!