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by rcdmd
2622 days ago
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The conclusion is basically this (the last sentence before the "conclusion" section...
> But it does mean that we cannot afford to compound these problems through the use of an RCA tool that is so deeply and fundamentally flawed. Other more systems-focused techniques, such as fishbone75 or lovebug diagrams,72 causal tree diagrams,21 Causal Analysis based on Systems Theory (CAST)76 or even prospective risk assessment approaches,77–81 should be considered instead. I find it odd that the paper cites so many theoretical problems with "5 whys" and then elevates these other methods as preferred solutions without any discussion. It's possible RCA committees already recognize the limitations of "5 whys" and use it as a heuristic that helps focus their efforts. That doesn't mean these committees all sit around a table and say "well, X sounds like a major problem, but it doesn't fit our '3rd why,' so we have to ignore it." |
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