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, root cause comes from change. Something didn’t change and it should have, or something changed and wished it really hadn’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 is made and they combine 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? How did they know which to change to select?

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 works, and the most recent change is the change that caused the issue. But what about when we have a complicated problem?

Creating a change balloon anchor using distinctions

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 a unique property, or something that is special, odd, unusual, or unique that affects the “thing” or object that has the problem when compared to a similar “thing” or object that could be experiencing the problem but does not. We look at multiple areas for unique properties including:

WHAT type of symptom, error or problem is occurring vs. WHAT type of symptom, error or problem could be occurring but is not.
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.
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.

Examples of Distinctions:

The users having the issue are only on the 3rd floor and the users on all the other floors are fine.
The machine that is failing is connected to a separate pneumatic line compared to the ones that are working.
The ingredients used in this drug use a different binding agent than the ones that are not having a problem.
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 (underlined in the examples above).

Finding the relevant change balloons

After creating and naming your anchors, it’s now time to turn to the sky and examine all those change balloons once again. Yes, the balloons are a bit further away than when we started since we took the time to figure out our unique properties and create anchors, but this time we have a strategy to find the balloons that matter! When we scan the sky, this time, we only look for changes around or anchor names/unique properties.

For Example:

Did we update our wifi router on the 3rd floor?
Recently perform maintenance on the pneumatic line?
Use a new shipping supplier for the ingredients that make our binder agent?
Since all these changes are related to an anchor name, These would all be considered changes that we should pay attention to!

Creating strong possible causes

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!