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by danmil
4937 days ago
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Heya, author of the slides here. Re: 'root causes' -- I find the words somewhat important. Like, if you say you're looking for a root cause, then people tend to be in the sort of moral mindset, and have a harder time seeing it as a collection of contingent events. Also, in the (truly amazing) "How Complex Systems Fail", he's pretty down on "root cause": http://www.ctlab.org/documents/How%20Complex%20Systems%20Fai... "7) Post-accident attribution accident to a ‘root cause’ is fundamentally wrong" |
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The point of the exercise is to identify economical interventions that will get the system to produce better results. If you go much beyond that, people can get off into moral, analytical, or philosophical weeds and get lost.
As long as you do retrospectives and five-whys frequently, you can count on useful analytical depth to come over time. If an issue is really both important and subtle, it will crop up again. The next time you'll have another perspective, so it will be easier to find. And by waiting, you'll have avoided examining all the equally subtle but unimportant things.