[devonkim]

One other important point is that the very term "root cause" is extremely harmful in that it presumes a primary failure and already seeds the idea of one bad actor and, by proxy, blame. Systems today are too complex to blame upon one or two things - we operate in a very complicated, "complected" world both in our software and in many organizations.

While there are always technical causes for larger technical failures, I've seen far too many times RCA post-mortems performed that result in witch hunts instead of a solemn contemplation of how things could be better done by everyone. Such an RCA may ignore that a normally careful engineer was overworked by managers, never is lack of relevant monitoring and testing due to budget cuts cited, and you'll certainly never see "teams X and Y collaborated too much" as a reason for failure in these places. Because in a typical workplace, the company's values and culture are never related to a failure. You can't objectively measure how bad or how good a culture is either. Why make it part of post mortems when you don't think it's a failure?

[hinkley]

I don't recall ever having a manager use the term root cause analysis in the way you are implying. Usually we are looking for the cheapest or most effective process change that will prevent that class of problem happening again.