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> The Five Whys specifically does not stop at a single root cause or fault, that's why it's the five why's and not the one. The Five Whys is a good start. It g
by bobsomers 6y ago
> The Five Whys specifically does not stop at a single root cause or fault, that's why it's the five why's and not the one.
The Five Whys is a good start. It gets you thinking past the first cause you see. But it still suggests that there is a single causal chain with a single root issue. Something like STAMP is designed to find any possible contributing factors, whether they are related in a causal chain or only had an indirect impact on the loss.
> Moreover, robustness cannot emerge from a single event no matter how much you analyze it. It comes from continuous improvement processes, quality assurance, war games, service level analysis, etc. It's a multi-headed hydra of efforts to improve a system.
I don’t think I said anything which contradicts this, and I generally agree. The point I was, perhaps unclearly, trying to make is that by including any possible contributing factor in your analysis, you can fix many issues you learned about from a single event. Issues which may have been contributing factors to future, different events. One loss is not enough to fix all the holes, but you want to learn as much as you possibly can from each one when it happens.