Oeps foutje – € 310.700,- aan onterechte boetes


Vorige week verscheen een opmerkelijk bericht in het nieuws: Honderden onterechte boetes….want mensen die door groen reden werden beboet! (zie: http://nos.nl/artikel/2172834-onterecht-honderden-boetes-na-foutieve-reparatie-flitspaal.html). Aangezien de boete €239,- per stuk was en het hier om minstens 1300 personen gaat, is het bedrag opgelopen tot €310.700,-.

Hilarisch natuurlijk en ook vervelend voor de gedupeerden. De uiteindelijke “schade” is veel groter en niet zo hilarisch. De door rood-rij boetes zijn nu niet uitgeschreven, door het uitzetten van de flitspaal loop de overheid ook inkomsten mis en wat te zeggen van de administratieve rompslomp die dit met zich mee heeft gebracht. Een incident waar toch even van geleerd moet worden.

Dat heb ik gedaan door er een plaatje van te maken. Het plaatje verteld meer dan 1000 woorden en maakt inzichtelijk hoe de vork in de steel zit. Het plaatje wordt een  echt praat plaatje (hoe anders met platte tekst!). (click om te vergroten).PPM Groen Licht

Uiteraard – beperken van de schade (uitzetten camera) en uitzetten van de actie om de kabels juist te installeren zijn de zaken die logisch naar voren komen. Maar laten we eens verder denken. Hoe kunnen we pro-actiever met dit incident omgaan? Hoe te voorkomen dat het in de toekomst weer fout gaat? Uit het plaatje kan ik een aantal andere mogelijke acties formuleren:

  1. Wat is de oorzaak dat er dit keer niet getest is? Hoe kunnen we dat voorkomen?
  2. Moet het onderhoudsplan van verkeerslichten aangepast worden?
  3. Zouden de kabels zo gemaakt kunnen worden dat ze “fail-safe” (en dat omdraaien niet mogelijk is, net als je USB stick in je computer)

Deze ideeën voeg ik toe aan het plaatje:

PPM Groen Licht met acties

Overzicht creëert inzicht, met als doel incidenten te voorkomen.

Ik ben benieuwd wat er in werkelijkheid wordt gedaan. Hopelijk ontspringen de gevaarlijke door-rood-rijders niet langer aan de dans.


Mind the gap! Or can’t you be bothered?


I like to run, and I am fanatic enough to keep track of my distance, pace and heart rate, on every run. It is like a numbersgame, a competition with myself. But there is this gap between me and breaking my personal best, running the 10k within an hour. How come I am not improving? Probably (well certainly) the lack of proper training, coaching and a schedule are what is missing. So to improve – I need to invest and set some priorities.

What about organisations? How do they get better? Do they invest enough to break records and crossing lines for the greater good? Like reached the lowest level of scrap, reduced the number of recurring problems, achieved an amazing uptime due to a minimum number of interruptions, or an all- time low use of unnecessary spare parts? Recently a client said to me: I have managed all the bottlenecks in the system, now I need to go to the next level. And…there is this gap, in problem solving:

Closing the gap in problem solving would have a moderate to extremely high impact on quality.

Wow! This is the outcome of a study conducted by Deloitte and the Automotive Industry Action Group (AIAG). It was looking into the future with OEMs and suppliers in the automotive industry. The report, called Quality 2020 showed a shocking result:

Problem-solving capabilities are inadequate, and the main reason is because we are jumping to solutions

How come an industry with many years of experience, that is normally ahead of the game, is still lacking these key capabilities?

Problem solving is important because it impacts the organization’s ability to manage, monitor, and respond to quality-related events; the ability to implement operational efficiencies as well as brand and customer relations.

It is recognized as a key differentiator, so why not invest in that key capability? Problem solving is not like fixing the same problems over and over again. That is just fire fighting. You think you can manage uptime and reliabiilty with that? When root cause is still lacking and people rush from calamity to catastrophe, from disaster to crisis, I am afraid you have some homework to do.

Like running. If I want to improve, I need to get serious. Get training, make it systematic, get a coach and a training schedule. Unfortunately, a one-size-fits-all approach will not give the biggest improvement. I should get a “current state” test as well, to make sure the training suits best with my current condition and situation.

Likewise with problem solving. Although a lot of people think when more experienced one will be better at problem solving. Well, just a bit, but you will not be able to make the big jump to break your personal best. There is a jump needed to bridge the gap between solving simple and tough problems. And when becoming confident in solving them, you feel empowered to go beyond and become even more proactive in your approach.

But first things first, and step by step. Think about your priorities. Do you want to improve, do you want to breakthrough the magic barriers? Then it is time to invest.


I don’t know – do you?



One of the most frustrating aspects of problem solving is not knowing what the problem is. How can I fix this horrible, unwanted situation! This black box is staring at you and people would say “I don’t know what the problem is”. Of course not, as you’ve just started the investigation!

How should you know?

  1. Your colleague How often does it happen that in hindsight a colleague did know how to solve the issue? How come you didn’t know about it? Was it not documented in the system? Was it only captured on his internal hard drive? And why didn’t he tell you when you explained to him what was going on?
  1. The system The system comes up with a “perfect match”, or you thought you found the perfect match. The result provided had the most similarities to the situation you entered. In reality the perfect match was not so perfect after all and the solution provided took you totally off piste and made the situation even worse. The question arises – how well was your description of the problem and how precise was the documentation captured in the system?
  1. You Although you said you didn’t know, how come you should actually know?

If you don’t know, start to understand first.

Problem solving doesn’t start with knowing what the problem is. It actually starts with understanding. Good problem solvers are conscious about the difference between solving and understanding.. “Seek to understand before seeking to solve” is a principle derived from one of the 7 habits of effective people of Steven Covey and is one of the core concepts of KCS (defined by Consortium for Service Innovation, enabling knowledge management) .

Kepner-Tregoe defined this principle already in their studies in the 1950s. They designed the Situation Appraisal process for it. Getting a good understanding of an issue means you need to:

  • Collect the facts – to make sure the starting point is right. The questions “What is exactly going on? What evidence do you have? What should be happening vs what is actually happening?” are giving you a powerful insight in the situation.
  • Ask open questions – to make sure to you get all the issues from the customer’s perspective. Closed questions are dependent on what you know, …and that was exactly the issue, you don’t! Closed questions are often based on assumptions and can very easily lead to the rabithole.
  • Ask for clarification – rather than concluding on your own, ask “What do you mean by?” and you will be surprised by the answer. As what is being said is often not what is being meant. And evenso, what did you get out of it?
  • Separate issues – rather than lump things together. By structuring and organizing issues in separate buckets, they become easier to tackle and to prioritize. Because how sure are you that all these issues can be cured by the same medicine? If you think making it yourself easy by summarizing the separated issues in general terms, you are wrong. It is actually making it yourself extremely difficult to fix the issue. One size doesn’t fit all. Move away from container language and be as specific as possible, by splitting up different symptoms and facts.
  • Listen objectively – with an open mind and both ears, leaving your “map of the world” at rest. We often listen to interrupt or are already busy in preparing the response. Listening with full attention isn’t that easy, but give it your best.

But will I get to know my problem?

By embracing “seek to understand before seek to solve” principle, or in KT terms by doing your Situation Appraisal right, you will notice that:

  • The dialogue with your customer gets fluent
  • Your customer is willing to offer more information because of your quality questions and structured approach
  • You understand more about the situation, enabling you to ask for more specific help of your colleagues
  • The search in the knowledge system becomes more specific and hits become more reliable
  • The system, where all knowledge resides, becomes more meaningful as all people put in more precise information
  • You will solve this issue!
  • (And ..your customer satisfaction scores go up)

Problem solving starts with not knowing what the cause is. And it should be your aim to get a better understanding of what the problem exactly is, so you can solve it permanently.

An example from reality

Recently I coached an equipment engineer on a problem that was open for half a year. He had put down the problem description: I can’t operate the machine from the user interface and the read outs are too low. Two issues mentioned in one sentence, triggered by the word “and”.

Let’s separate them first, as how do you know that it is caused by the same cause? He didn’t know.

Understanding reality means to ask a question: “So how you know the read out is too low? What do you see? What is actually happening?”  

“Uhm, well it has been a while, but I think…” and the engineer made up a story.

Later on he asked permission to go to the cleanroom. “Why do you want to go there” ,I asked, as I was afraid he would go and change something. “To get a better understanding of the problem”. 20 minutes later he came back with screenshots and all actual measurements of the screens and interfaces. Now he could start to understand the issue, before jumping to the solution of it. And he discovered he had more than 2 issues at hand.

It felt like going back and not moving forward. The starting point now is much better.


Problem Solving – difficult puzzle or kids play?

After a busy year-end, the winter break allowed me a few days at home for a little relaxation and self-indulgence and, as is the tradition in my house, the completion of a 1000 piece puzzle. It is an extremely relaxing activity for body and mind as eyes search and hands reach out for lumpy-edged pieces and the mind wanders and drifts but slowly the picture starts to appear and I reflect upon the parallels between this holiday hobby and the troubleshooting techniques of my working life :

Starting with the boundaries

EdgeUnpacking the box, eager eyes are not distracted by the colours and shapes of the broken image. First task is to seek out the limits and find all the pieces with the straight edges to “scope” the puzzle and set the boundaries. In problem solving this phase is executed with the start of a problem statement: what is the object and its deviation? Then we search for data and organize it in order to construct a clear picture from the outside in.

Constructing the elements to make building blocks

Building blocksWith the limits set, it is always a challenge for where to begin. Expert puzzlers will aim to build around the distinctive features and obvious, almost easy to fit, puzzle pieces. In troubleshooting issues, some facts are easy to find and are immediately brought to the table while others require more perseverance and keen observation; which means that the right conditions help, such as good illumination and enough room to layout the pieces and ensure no evidence is hidden.

In the beginning, there seems an overwhelming amount of these interdependent elements, you almost don’t know where to look to find the pieces that fit. Some can be overlooked through obsessive searching for that specific piece that fixates for the moment, while other times we can stumble across a key item that was not the objective of our search.

So true too in our troubleshooting since we often become fixated upon a possible root cause and seek out the evidence at the risk of missing other key data. Important then to keep an open mind and maintain a rigorous process that builds islands of what we know to be true to bring the big picture into focus; we soon have more solid evidence than spaces in between and there is a final rush of activity to fill in the gaps with what is left.

It is all about close observation and logic

logicWhen the easy bits are done, the most difficult stage starts: the look alike parts. The key capability here in making progress is the ability to observe very closely . A friend was really good at this – staring at the pieces, comparing each carefully against the other, and then all of a sudden taking one piece and just fitting it in the right spot! It is the unique characteristics of the piece that needs to fit the confirmed surroundings that helps you further. “ What is special odd unique or distinct” is the key question to ask. The trial and error approach took definitely much longer and was actually distracting the others around the table.

The problems we face are the ones where  there is a lot at stake. And even then, we come across the trial and error attempts to solve the problem. When actually starting to look closely at the facts, using a logic approach, the group immediately recognizes their attempts were a waste of time. And the question “if this fix is the cause, why it is happening in this range of products and not in that other range of products”? is a simple one, but saving you big time. Unfortunately, a lot of effort, money and parts are already spent, without having a clear path to permanent solution. Taking a step back and focussing on the unique characteristics and the related changes is often the course of action that allows you to make progress. Like in a puzzle, there is only one solution possible.

Problem Solving – is it just a kids play?

Standing back, looking at the completed picture it all seems so right, so obvious.

Is problem solving as easy as finishing a jigsaw puzzle? Of course not! But even so, the frustration levels can be the same, as well the feeling of contentment at another puzzle resolved.









Speed up – we need it fixed!

Acting quickly to put out the fires

I wrote in a previous post about the need to regroup and really examine a situation in order to get clarity about what is happening and where we When the pressure to act is high--Lessons for IT support under pressureneed to start looking to resolve a problematic situation. Obviously there are times when urgent action is required, we simply do not have the luxury of time and even a thirty-minute delay is too costly to the business.

If your company is losing $50K per minute due to a critical incident, then you need to move, and move quickly. Managing the effect is the critical driver in IT environments and requires clear thinking and effective action. When there is a fire in a building, the fire brigade doesn’t pull a team together to start to plan their actions. An organized set of well-orchestrated actions–that have been rehearsed over and over again—are quickly taken. Because the team is prepared and running on ‘auto-pilot;’ things are managed properly.

A scattergun approach will not work

When something major goes seriously awry and the business is depending on you to make it right, you need the orchestrated action of a fire brigade. Yet too often people run in different directions to try and make things right. With luck, one of those actions will work, but there is a good chance that any one of these ‘solutions’, in isolation, will not be successful. In a worst-case scenario, you may even exacerbate the problem, making it worse and more complicated to resolve. The longer an incident goes on and the more attempts at applying fixes, the further you are from understanding what happened.

Thinking correctly under pressure

A sense of urgency can be counterproductive, unless thinking correctly under pressure is ingrained in the culture of the organization. Taking the time to correctly assess the situation is not intended to slow business down; the key is to enable structured problem solving to begin as quickly as possible when issues occur by training the brain to think and use experience efficiently

Speed up the process by using process

There are clever people working in IT. They can assess the situation and match it to similar events they have encountered in the past, considering and discarding possible solutions as they go. But they need tools to support and speed up this process and quickly identify a subset of feasible solutions to a crisis situation.

People working in emergency services—whether it is a fire brigade or an IT support desk– need a standard set of checks to obtain the facts, quickly take stock of a situation and— seemingly without thinking—take the right course of action. They are actually thinking in a deliberate way, matching the situation to previous scenarios faced; noting any differences, considering actions taken and weighing value of these actions in the current crisis. In this way, they can use experience effectively, testing it against current facts, rather than jumping to action immediately. (oops sorry, patient died, but my process worked)

A cool head in a crisis

The ability to keep a cool head in a crisis can be a natural personality trait (nature) or it can be cultivated (nurture) by developing successful problem solving strategies in an environment that encourages and rewards using them. Creating a culture that embraces a clear thinking approach to emergency actions helps IT teams succeed and thrive in a crisis.