| We haven’t acknowledged that trying to ‘find causes’ at all is misleading! Causes are something we create and construct afterwards. They aren’t a primitive that make up incidents. They don’t fundamentally exist to be found. Causal explanations limit what we find and learn and the irony is that root cause analysis is built on an idea that incidents can be fully comprehended—they can’t! Instead think about the conditions that allowed an incident to occur. Separate out everything you think looks like a cause and explore each of them. Talk about the properties and attributes that were present. There are so many aspects to incidents that aren’t even causes at all, and they don’t follow a linear chain of this-led-to-that. People are presented with RCA and 5 whys as really getting to the bottom of what matters, but the reality is this approach is a linear simplification. We need to kick it up a notch and practice more holistic investigations of incidents. Stop getting at why people didn’t do what they thought they should have done, and start getting to the point of what actually happened and how those actions seemed reasonable at the time. https://www.oreilly.com/ideas/the-infinite-hows |