ROI Case File No.218 | 'The Eastern European Telecom Company's Lost Voice'

Chapter 1: Frequent Failures—Instability Hidden in Growth's Shadow

A few days after the resolution of CloudSync Solutions' NPS improvement case, a serious consultation arrived from Eastern Europe concerning a critical infrastructure company.

"Detective, our telecommunications service is plagued by frequent failures, and customer defection won't stop. Technically there should be no problems, yet troubles keep recurring."

EuroComm Networks CTO Petr Novák visited 221B Baker Street, unable to hide his confusion. In his hands were system failure reports from the past 6 months and customer cancellation data.

"We are a company providing telecommunications infrastructure services across Eastern Europe. Due to 5G deployment and digitization demand, our business is rapidly expanding, but service quality issues are causing continuous customer loss."

EuroComm Networks Business Overview: - Service area: 8 Eastern European countries, 120 major cities - Customers: 2,800 corporate clients, 1.8 million individual customers - Annual revenue: ¥120 billion (+35% growth from previous year) - Infrastructure investment: ¥45 billion over past 3 years - Employee count: 3,200

The numbers certainly indicated a rapidly growing telecommunications company. However, Petr's expression held serious concerns.

"The problem is that despite making the latest equipment investments and establishing industry-leading technical infrastructure, system failures occur 15-20 times monthly."

Service Failure Status Over Past 6 Months: - Major failures: 3-4 times monthly (service outages 30+ minutes) - Medium failures: 8-10 times monthly (specific regional issues) - Minor failures: 15-20 times monthly (individual customer impacts) - Customer churn rate: 4.2% monthly (over double industry average of 1.8%)

"What confuses us most is that similar failures keep recurring. We should be implementing countermeasures, yet we never reach fundamental solutions."

Chapter 2: Invisible Roots—Limitations of Surface-Level Measures

"Mr. Petr, could you tell us about your response processes when failures occur?"

Holmes inquired quietly.

Petr answered while retrieving the failure response manual.

"We've established standard failure response processes. The flow is: failure occurrence → cause investigation → emergency measures → fundamental countermeasures → recurrence prevention."

Typical Failure Response Case:

Case 1: Prague Communication Failure (March 15) - Failure details: 3-hour communication blackout in city center - Affected customers: 120 companies, 8,500 individuals - Immediate response: Backup line switchover (restored in 45 minutes) - Cause investigation: Main router overload identified as cause - Countermeasures: Router expansion and traffic distribution configuration

Case 2: Same Prague Recurrence Failure (April 22) - Failure details: Same city center area, 2-hour communication blackout again - Affected customers: 85 companies, 6,200 individuals - Cause: "Different" router overload - Countermeasures: "Additional" router expansion

Case 3: Same Prague Third Failure (May 30) - Failure details: Same area, 1.5-hour communication blackout - Affected customers: 95 companies, 7,100 individuals - Cause: Configuration error on "newly installed" router - Countermeasures: Configuration review and enhanced checking system

I focused on the recurrence pattern.

"The same region has experienced similar failures three times. Technical countermeasures have been implemented, yet why do they keep recurring?"

Petr answered with a confused expression.

"That's the problem. Each time we can identify the 'cause' and implement 'countermeasures,' but similar problems end up recurring."

Similar Patterns Occurring in Other Regions: - Warsaw: 5 similar failures in past 4 months - Budapest: 4 similar failures in past 3 months - Bucharest: 6 similar failures in past 5 months

"We're addressing 'symptoms' but may not be reaching the 'root of the disease.'"

Most Serious Customer Feedback:

"We understand the technical explanations, but the recurrence of similar problems is a reliability issue" (Major Manufacturing Company IT Manager)

"More than individual failures, we question why they can't be prevented" (Financial Institution Systems Director)

"EuroComm has excellent technology but seems to have operational management problems" (Government Agency Procurement Officer)

"Customers view this not as 'technical problems' but as 'management problems.'"

Chapter 3: The Answer 5 Whys Led To—Pursuit of Root Causes

⬜️ ChatGPT | Catalyst of Ideas

"By repeating 'why,' you can reach layers of truth. The essence hidden in surface layers emerges."

🟧 Claude | Alchemist of Narratives

"Story truths always lie deep. Five questions resemble foreshadowing recovery in mystery novels."

🟦 Gemini | Compass of Reason

"Without drilling down to problem root causes, countermeasures become castles built on sand."

The three members began their analysis. Gemini developed the "5 Whys Analysis" framework on the whiteboard.

5 Whys Analysis Method: 1. Clear definition of problem phenomenon 2. Repeat "Why did this problem occur?" five times 3. Identify true causes at each layer 4. Formulate countermeasures for root causes

"Mr. Petr, let's analyze Prague's recurring failures in detail using 5 Whys."

Prague Failure 5 Whys Analysis:

Problem: Similar communication failures occurred 3 times in Prague city center

1st Why: Why do failures recur in the same region? → Answer: Because router overloads repeatedly occur

2nd Why: Why do router overloads repeatedly occur? → Answer: Because traffic predictions are inaccurate and equipment capacity is insufficient

3rd Why: Why are traffic predictions inaccurate? → Answer: Because load status reports from the field don't reach headquarters accurately

4th Why: Why don't reports from the field reach accurately? → Answer: Because field staff feel that "reporting problems will negatively affect evaluations"

5th Why: Why do field staff hesitate to report problems? → Answer: Because the company culture prioritizes "zero failures" above all, and problem reporters face blame

Claude reported a shocking discovery.

"This isn't a technical problem. It's an organizational culture issue. The structure where field voices don't reach management is causing technical problems."

Other Failures Also Analyzed with 5 Whys:

Warsaw Failure Root Cause: - Surface cause: Equipment maintenance deficiency - Root cause: Maintenance staff recognized "abnormal equipment sounds" 3 weeks prior but didn't report - Reason: Judged "still functioning so no problem," feared being seen as "overly nervous" if reported

Budapest Failure Root Cause: - Surface cause: Software update malfunction - Root cause: Field engineer felt there were "risks" before update but executed per schedule priority - Reason: Culture where reporting schedule delays is seen as "lacking planning ability"

Bucharest Failure Root Cause: - Surface cause: Power system trouble - Root cause: Electrical engineer observed minute voltage fluctuations 1 month prior but didn't report - Reason: "Still within standards," concern about being seen as "exaggerating"

Common Root Cause Discovery: "Culture where field concerns and early warnings don't reach organizational leadership"

Organizational Culture Problem Structure: 1. Perfectionism Pressure: Zero failures as absolute requirement 2. Blame for Reporters: Problem reporters treated as "people who caused problems" 3. Evaluation of Response Over Prevention: People who solve problems after they occur get evaluated 4. Headquarters-Driven Decision Making: Headquarters makes decisions without understanding field conditions 5. Failure-Intolerant Culture: Small problem reports seen as "evidence of incompetence"

Chapter 4: Voices That Didn't Reach—Silent Field Reality

Detailed field surveys and employee interviews revealed the fundamental organizational problems at EuroComm Networks.

Anonymous Field Staff Interview Results:

Engineer A (Prague base, 8 years experience): "I noticed router loads increasing 2 months ago. But since it was 'still within normal range,' I didn't report it. In the past, when I made similar reports, I was told I was 'too nervous.'"

Maintenance Staff B (Warsaw base, 12 years experience): "I definitely heard abnormal equipment sounds. But since it was still working, I thought I'd watch a bit longer before reporting. If I report, it becomes a 'big problem,' so I wanted to wait until it was really necessary. Unfortunately, it became a major failure."

Technical Manager C (Budapest base, 15 years experience): "I knew there were risks with the update. But headquarters' instruction was 'strict schedule adherence,' so I felt that reporting risks would be seen as 'making excuses.'"

Structural Problems Preventing Field Voices from Reaching:

Psychological Barriers to Reporting: - Small problem reports → "Worrying too much," "Nervous" evaluations - Risk pointing out → "Negative," "Uncooperative" impressions - Preventive proposals → Rejected as "unnecessary costs" - Early warnings → Recognized as "people creating problems"

Reverse Incentives in Evaluation System: - Evaluated by length of failure-free periods (prevention not evaluated) - Evaluated by rapid response during failures (emphasis on post-incident response over prevention) - Evaluated by cost reduction (preventive investment seen as "waste") - Evaluated by schedule adherence (safety over efficiency priority)

Communication Structure Problems: - Complex field → headquarters reporting route (5-level approval) - Middle management reluctant to convey "bad news" - Headquarters executives lacking field understanding - Lack of translation from technical concerns to business meaning

Comparison with Competitors:

Excellent Competitor A (Failure rate 1/5 or less): - "Good Catch" system: Evaluates small problem discovery - Direct reporting route from field (CEO direct hotline) - Active approval of preventive investment - Failure-tolerant culture ("Perfect prevention is impossible" premise)

Critical Differences from EuroComm: - Prevention vs. post-incident response - Field emphasis vs. headquarters-driven - Failure tolerance vs. perfectionism - Early detection encouragement vs. problem concealment tendency

Petr was stunned.

"We thought it was a technical problem, but it was actually an organizational problem where we couldn't hear field voices."

Chapter 5: Detective's 5 Whys Analysis—Deduction Pursuing Root Causes

Holmes compiled the comprehensive analysis.

"Mr. Petr, the essence of 5 Whys is 'drilling down from surface symptoms to fundamental causes.' Many technical problems actually stem from organizational issues."

5 Whys Analysis-Based Organizational Culture Reform Plan:

Root Cause Countermeasures: Building Organizational Culture That Utilizes Field Voices

Phase 1: Ensuring Psychological Safety (3 months)

Introduction of Reporting Encouragement System: - "Good Catch Award": Evaluate small problem discovery - Active encouragement of early warning reports - Anonymous protection for reporters - Evaluation system for preventive problem raising

Transformation of Blame Culture: - Instill value that "problems are improvement opportunities" - Establish "No Blame Culture" that doesn't blame reporters - Build mechanisms to learn from failures - Management commitment to cultural transformation

Phase 2: Communication Structure Reform (2 months)

Mechanisms to Convey Field Voices: - Direct reporting route from field to CTO - Weekly field rounds by management - Visualization of technical concerns' business impact - Rapid consideration and approval process for field proposals

Information Sharing System Construction: - Sharing problem and countermeasure information across all bases - System to prevent similar problem horizontal expansion - Field knowledge database creation - Best practice standardization

Phase 3: Prevention-Focused Organizational Management (Ongoing)

Evaluation System Transformation: - Evaluate failure prevention achievements - Evaluate early detection and reporting - Evaluate preventive investment proposals - Emphasize long-term stability

Continuous Improvement Culture: - Regular 5 Whys analysis implementation - Continuous tracking of root causes - Measurement and evaluation of preventive effects - Organizational learning systematization

Implementation Schedule: - Month 1-2: System design and personnel education - Month 3-4: Pilot base verification - Month 5-6: Company-wide deployment

Expected Effects: - Failure occurrence rate: 20 times monthly → 5 times or less monthly - Preventive problem discovery: 50+ cases monthly - Customer churn rate: 4.2% → 1.5% (below industry average) - Employee engagement: +40% improvement

"The key is recognizing that many technical problems stem from organizational issues. Culture that utilizes field voices leads to true problem resolution."

Chapter 6: Revival of Field Voices—Root Cause Resolution

Eight months later, a report arrived from EuroComm Networks.

Results from 5 Whys Analysis-Based Organizational Culture Reform:

Dramatic Failure Rate Improvement: - Monthly failure count: 20 cases → 3 cases (85% reduction) - Major failures: 3-4 times monthly → 0.2 times monthly (95% reduction) - Customer churn rate: 4.2% → 1.1% (industry-leading level) - Service uptime: 97.2% → 99.7% (significant improvement)

Field Voice Utilization Results: - Early warning reports: 52 cases monthly (major preventive effect) - Good Catch Award recipients: 18 cases monthly - Preventive improvement proposals: 31 cases monthly (80% adopted) - Direct reports from field: 8 cases monthly (early detection of important issues)

Organizational Culture Transformation Effects: - Employee satisfaction: 3.1/5 → 4.6/5 (significant improvement) - "Can report safely": 28% → 89% - "Company values field": 22% → 84% - Turnover rate: 18% annually → 6% annually (recovered to normal level)

5 Whys Method Establishment: - All managers completed 5 Whys training - Standardized 5 Whys analysis during problem occurrence - Root cause countermeasure implementation rate: 100% - Recurrence prevention effect: 95% achieved

Customer Satisfaction Improvement: - Customer satisfaction: 3.4/5 → 4.5/5 - Service reliability evaluation: +180% improvement - Contract renewal rate: 68% → 94% - New customer acquisition: +35% increase through word-of-mouth effects

Preventive Investment Effects: - Preventive equipment investment: ¥1.5 billion annually - Loss reduction from failures: ¥4.5 billion annually - Investment return: 300% (significant profit contribution) - Technology capability evaluation: Significant improvement within industry

Industry Position Change: - Technical reliability ranking: Lower tier → Top 3 - Customer recommendation rate: Significantly above industry average - Engineer recruitment: Increased applications from excellent talent

Petr's letter contained deep gratitude and learning:

"Through 5 Whys analysis, we discovered fundamental organizational problems hidden behind surface technical issues. Most importantly, we built a culture where field voices are heard. By creating an environment where engineers can safely report concerns and make preventive proposals, we achieved true technical reliability. Now failures are not 'things to handle after they occur' but 'things to prevent beforehand' - this recognition has permeated the entire company."

Detective's Perspective—Deep Insight into Root Causes

That night, reflecting on the case, I pondered.

EuroComm Networks' case clearly demonstrated the "surface problem-solving trap" that modern companies often fall into. Many issues that appear as technical problems actually stem from organizational and cultural problems.

The true value of 5 Whys lies in peeling away problem layers one by one by repeating "why," reaching true root causes. Addressing only surface symptoms results in the same problems recurring in different forms. Without cutting the root, there's no true solution.

Particularly important was building organizational culture that utilizes field voices. Fields often contain important information for early problem detection and prevention. However, without an environment that makes reporting easy, valuable information gets buried.

"True problem-solving begins with deep insight into root causes."

As the eighth case in Volume XVI "Quest for Agility," EuroComm's case showed important lessons. Agility is also the ability to identify root causes rather than surface symptoms and address them organization-wide.

"The true form of problems doesn't appear on the surface. Only through five 'whys' can we reach fundamental truth. And the courage to face that truth creates true improvement."—From the Detective's Notes