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This is a rant that I've had for so long, and it's so hard to concisely summarize. This does a great job of explaining in detail, but it is much harder to tell
by darksaints 8y ago
This is a rant that I've had for so long, and it's so hard to concisely summarize. This does a great job of explaining in detail, but it is much harder to tell your boss to read a long blog post when you disagree with him about the correct approach. I found a metaphorical approach to sometimes be helpful. I use this:
On a dark night, a blind man jaywalked and was nearly hit by a drunk driver who swerved and killed a pedestrian wearing black on the sidewalk. What was the root cause? Was it because the man was jaywalking? What if he was jaywalking because he was blind and didn't know any better? If the driver wasn't drunk, could he have braked instead of swerving? If the pedestrian was wearing brighter colors, could the driver have swerved a different direction? Sometimes there is no singular root cause, but rather a complex interaction of multiple failures that may or may not arise if you take one failure away. There may be a better approach than to use a tool that is designed to hone in on a singular root cause.
Unfortunately, this only sometimes works. The rest of the time, they actually do try to pick apart the example and claim there is a root cause. The only recourse then is to present an alternative singular root-cause and say that by trying to force a single root cause interpretation instead of accepting the complexity of reality, that your root cause will ultimately reflect your own biases rather than reality (for example, who do you hate more: jaywalkers, drunk drivers, or pedestrians that wear black at night?).
I still wish I had a better way of explaining this succinctly, in a way that makes it more clear.
- vkou 8y agoThe real man at fault here, of course, was the bartender that served the driver his last drink. Isn't it obvious? /s
- Zak 8y agoCourts have held that to be true before and even gone farther, finding the bar ultimately responsible for failing to train or supervise the bartender to prevent such an outcome. This is probably mostly because bars usually have larger insurance policies than drunk drivers.
- mechanismo 8y agoNo, it's the car that allowed the drunk person to drive it. The corrective action is cars should have breathalyzer interlocks as standard equipment. I'm not actually joking - applying this process seriously requires looking at not just who did what (people) but the presence or absence of mechanisms. Corrective actions that rely on the good intentions of people "remembering to do the right thing" rarely work. I review several RCAs a week in my job. If I saw one for a scenario like this where the actions or inattention any of the humans involved here was identified as the ultimate root cause, it'd get kicked back for re-work.
- c22 8y agoHey now, the street also allowed jaywalking.
- a1369209993 8y agoPedestrians and heavy vehicles shouldn't be routed on the same level (/altitude/z-layer) in the first place.
- gowld 8y ago5 Whys doesn't find a "single root cause". I don't understand why you wrote a great example of how 5 Whys helps uncover issues to address -- drunk driving (which you could go deeper into -- why did the drinker need to drive? Why wasn't the drinker prevented from driving, or a driver prevented from drinking?), pedestrian visibility (and you could expand on that side -- why isn't the sidewalk more physically separated for the roadway?-- and then claimed that it's a failure.
- borvo 8y agoDon't bother explaining why it's wrong. Suggest something better.