Why it works when it works, and why it fails when it fails
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Your organization must have had incidents. An outage in the data center, a launch that missed. A strategy that looked right on the slide and never panned out. Something in your personal life that went sideways when you were sure it wouldn't. Something unwanted happened, and the first thing your mind reached for was one word: WHY.
To ask WHY, and to figure out WHY an unwanted thing happened so it doesn't happen again, is second nature. We do it in every meeting, every conversation, every time we talk to ourselves on the drive home. When we do it formally, we call it Root Cause Analysis. But formal or not, we are all doing it all day long. When we do it formally, it's the most structured, extensive and rigorous form of RCA.. the structure forces the rigor. Other times, it's just not rigorous.
And here's the thing most of you already know but rarely say out loud. This rigorous RCA does not work. You run the RCA, you fill in the template, you land on "the" root cause, and a few months later the same class of incident is back. Many in the room knew, deep down, it was a checkbox even while doing it. So you must have used that second nature and asked why RCA does not work. And what you were doing when you asked that question is RCAing the RCA itself. You did find an answer, didn't you. Ask "why" five times. Draw a fishbone diagram. Keep it blameless. Separate the root cause from the symptoms, and the list goes on. You've probably run offsites on these topics. And the same incidents keep coming back anyway.
So here is a question that should bother you. If RCA failed because people get defensive, or because blame shuts the room down, then RCA in your own head.. just you, no meeting, nobody to protect, no feelings on the line.. should work perfectly. It doesn't. You do bad RCA alone, in the shower, replaying the argument, reasoning about your own strategy that flopped. No one's feelings were ever at stake there, and you still got it wrong.
So feelings aren't the real problem. Not the primary one. Yes, blame can shut a room down, and feelings can get in the way.. that's real, but it's secondary. The primary problem is different. It's epistemological. It's people not understanding the difference between How and Why. The question is so basic that everyone believes they already know it, and so fundamental that giving a HOW answer to a WHY question will keep any RCA from succeeding.
So if you haven't trained your people on blameless postmortems, five whys, and the rest.. please don't start with the difference between How and Why. But if you've already trained them on all that, this is the thing that puts them on the right trajectory. And if you believe you already know the difference between How and Why, you could be right. But in case you're wrong.. it isn't what you don't know that puts you in trouble, it's what you believe you know that just ain't so.
Maybe it's time to do a Root Cause Analysis of Root Cause Analysis itself. And not just the engineers.. this isn't an engineering problem, it's a human one. Anyone who has ever asked WHY is already doing RCA, which means everyone.
So if you want a no-fluff, no-nonsense talk, with a mini case study each of you can relate to.. it will change your RCAs. And not just your RCAs. Remember, the formal RCA is only the visible tip.. we are all RCAing 24x7, in every meeting, every decision, every quiet argument with ourselves. It just happens that we do it formally for an incident. Fix the thinking underneath, and you don't only change how you run a postmortem. You change how you debug your life.
Call us. Let's talk about the incident that keeps coming back.