Problem Solving (Esp. During a Code Brown)

Problem Consciousness

• Identity the problem that is the priority

Clarify the Problem

• What should be happening?
• What is actually happening?
• Break the problem into individual problems if necessary
• If necessary user temporary measures to contain the abnormal occurrence until the root cause can be addressed.
• Locate the point of cause of the problem – Do not go into cause investigation (next step) until you find the point of cause.
• Grasp the tendency of the abnormal occurrence at the point of cause
• If necessary, “go and see”

Investigate Causes

• Identify and confirm the direct cause of the abnormal occurrence
• Conduct a 5-Why investigation to build a chain of cause/effect relationships to root cause
• Stop at the cause that must be addressed to prevent recurrence.

Develop and Test Countermeasure

• Take one specific action to address the root cause
• Try to change only one factor at a time, so you can see correlation

Follow Up

• Monitor and confirm results
• Standardize successful countermeasure
• Reflect. What did we learn during this problem-solving process?
• Share via retrospective/postmortem

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