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imo, the question "Why?" is really supposed to be more like "How could this have happened!??". It really makes a lot more sense that way. [edit: to respond to

by ajkjk 5y ago

imo, the question "Why?" is really supposed to be more like "How could this have happened!??". It really makes a lot more sense that way. [edit: to respond to the dead comment about what else "Why" could mean, the difference is the emotional valence. It's not asking the _factual_ question of how it happened; it's applying the appropriate outrage and embarrassment to the fact that it happened. "My god, we messed up! How can we ensure it never happens again, with urgency?".]

kqr 5y ago
Sure, but even better is to be more explicit: - Which business constraint was violated? - Why is that an important constraint? - What control mechanisms did we have in place to prevent that from happening? Have they prevented the constraint from being violated before? Why where those mechanisms insufficient this time? - What control mechanisms didn't we have? Why not? And so on. You get fan-out of much higher degree that way, but it also, in my experience, is a much more efficient way to search the causal network.
- ajkjk 5y ago
  I don't really agree. The model you describe presupposes a functional framework for decision making -- constraints are in place and respected; controls exist, etc. Most of the time the result of the Whys process is, in my experience: "oh, we really need a framework for constraints/controls/etc around this". I guess it looks very different depending on the business you're in and how codified everything already is. If you're investigating failures in, say, a manufacturing process, everything is pretty rigid already and you're finding problems with the rules you already have. If you're investigating failures in a hodgepodge software engineering organization, the problem is that there is no rigidity in the first place, and those processes need to be created from scratch. I'm mostly familiar with the latter, and usually the result of whatever you come up with is a place where leadership ought to be directly applied. (I'd hazard to claim that: if you do a 5-Whys in an organization and the leader of the organization doesn't see something that they can go fix directly -- not by delegating but by leading, themselves -- either you did it wrong, or they're a bad leader.)
alisonkisk 5y ago
What else does "why" mean?

by ajkjk 5y ago

kqr 5y ago

Sure, but even better is to be more explicit: - Which business constraint was violated? - Why is that an important constraint? - What control mechanisms did we have in place to prevent that from happening? Have they prevented the constraint from being violated before? Why where those mechanisms insufficient this time? - What control mechanisms didn't we have? Why not? And so on. You get fan-out of much higher degree that way, but it also, in my experience, is a much more efficient way to search the causal network.

ajkjk 5y ago
I don't really agree. The model you describe presupposes a functional framework for decision making -- constraints are in place and respected; controls exist, etc. Most of the time the result of the Whys process is, in my experience: "oh, we really need a framework for constraints/controls/etc around this". I guess it looks very different depending on the business you're in and how codified everything already is. If you're investigating failures in, say, a manufacturing process, everything is pretty rigid already and you're finding problems with the rules you already have. If you're investigating failures in a hodgepodge software engineering organization, the problem is that there is no rigidity in the first place, and those processes need to be created from scratch. I'm mostly familiar with the latter, and usually the result of whatever you come up with is a place where leadership ought to be directly applied. (I'd hazard to claim that: if you do a 5-Whys in an organization and the leader of the organization doesn't see something that they can go fix directly -- not by delegating but by leading, themselves -- either you did it wrong, or they're a bad leader.)

alisonkisk 5y ago

What else does "why" mean?