Beyond the Five Whys: Systemic Root Cause Analysis

Where Are We Now: Going Beyond the Five Whys

Everything I have been able to share in this book is a testimony to years of hard work and dedication to root cause analysis (RCA) and systems analysis by countless professionals in High‐Reliability Organisations and elsewhere (e.g. engineering, quality, medicine, internal audit, etc.).

I hope this book makes it clear that the ‘pure’ five whys, searching for just one root cause, is a technique that we seriously need to think about retiring in the twenty‐first century. I say this because although asking why is central to any RCA, the notion that there is a just one root cause, or a main root cause, can be problematic because of the way it effectively ‘turns its back’ on systemic considerations. In my experience, it often constrains and limits the thinking of those who get attached to the idea of finding a ‘main root cause’.

Fortunately, a narrow understanding of the five whys technique has been left behind by most experienced RCA practitioners, who use the five whys two legs, three‐way five whys, the Bowtie, the fishbone, fault tree diagrams or other techniques. This is why this book has been entitled Beyond the Five Whys. In each case, these other RCA techniques take the power of asking why but provide a much richer sense of why things can go wrong and what we might do to avoid problems in the future. So, the saying, ‘The future is already here – it's just not evenly distributed’2 rings true when it comes to RCA.

Having said this, my RCA work with clients over the past decade tells me that RCA techniques without a clear and explicit systems thinking perspective can be limited when seeking to get a full understanding of what has happened. This is why I developed the ‘eight ways to understand why, with connections’ (modified fishbone, with causal loops) technique outlined in this book.

And there are many other systems analysis tools and techniques (such as FRAM, SEIPS, STAMP, etc.) that I have not been able to cover in detail, but which are worth learning about. So, to this end, I have included, in Appendix B, a range of materials and links that can be a springboard for learning about other RCA and systems analysis techniques.

I want to stress, however, that readers should be mindful of getting attached to any particular RCA or systems thinking tool or technique, or combination thereof. And this includes the ‘eight ways to understand why, with connections’ in this book. I think it's a powerful technique and hope readers have found it to be a helpful ‘entrée’ into this topic; but neither it, nor any other technique in my opinion, represents ‘the last word’ on RCA and systems thinking.3

My firm view is that as we consider opportunities and threats, in organisations and the wider world, we should use, or pilot, whichever RCA and systems analysis tools and techniques that might help us. Thus, I strongly advocate being ‘multilingual’ in terms of different RCA and systems analysis tools and techniques. If you don't do this there is a chance you will stay in a single‐loop learning comfort zone, using what you like and what seems to work, but not necessarily getting fresh perspectives that may challenge and evolve your preferred approach.