4 ms·

Well yeah, going down the '5-Whys' it ends up being management to blame

fnordpiglet 4y ago
The flaw with 5 whys (not to say I don’t encourage it!) is they reflect the biases of the author while appearing unbiased and authoritative. So, it depends on who writes the post mortem who gets the blame.
- travisjungroth 4y ago
  Yes, because there’s insufficient room for reality. Causality is this big DAG with tons of incoming edges, going back to the beginning of time. 5 Whys is creating a path 5 edges long. This is often useful, but it’s not “the truth”. If each node has 10 incoming edges, there are 100,000 paths you could take. At least it’s better than root cause analysis, which is walking back until you want to stop and declaring that the root. The real root is the creation of the universe. I mean that sincerely. When you follow definitions of causality, time and the universe, you end up with the Big Bang as the root of your graph. Everything is else is editorializing.
  - bentcorner 4y ago
    "In the beginning the Universe was created. This has made a lot of people very angry and has been widely regarded as a bad move."
  - darkerside 4y ago
    To make an apple pie from scratch, you must first create the universe, as they say
- AnimalMuppet 4y ago
  A real 5 whys analysis probably should give a tree. Why did X happen? Because A, B, and C. Why did A happen? Because A1 and A2. And so on.
  - drivers99 4y ago
    Fishbone diagram is one way to do that https://asq.org/quality-resources/fishbone https://asq.org/quality-resources/fishbone
  - bluGill 4y ago
    You don't need to do that because there will be more 5-whys. Just pick whichever of A1, A2 seems like a bigger deal and find a B that seems like the biggest contribution - until you get to some deep root cause you can solve and mitigate. Then you fix that one issue and move one. You WILL see more issues, if they are always in other places you must have got the right one, if not then you will see this again and this time you can go down A2. The important part of the above is by refusing create the whole tree you actually get something solved. Sometimes you will get the right one, sometimes you won't. You can spend a lot of time building a tree of problems, and find tens of thousands of things you can fix - and now you have a larger todo list than you have time to do and likely you don't get anything done. Or analysis paralysis in other words.
    - fnordpiglet 4y ago
      This is specifically where bias comes in. People selectively prune the tree in ways that are either interesting (in a positive take) or deceptively based on their desire to avoid certain topics. Because the tree can be so large it isn’t always obvious even to the author whether they picked a branch because it was useful or because it served some other purpose - divert focus to a team they want to see behave differently, avoid taking blame for something, avoid being asked to fix something they don’t want to, etc. So, in this case the real question is “will they pick the branch that blames the people that pay and promote them, or take the branches that are of the least resistance.” Something this contentious would be vetted by committee in some way or another and at that point any upward finger pointing would be almost certainly curtailed in favor of a less contentious branch.
      - bluGill 4y ago
        Once again, there is only so many times you can keep re-running the same tree before someone will look for a different root cause. If you only run the process once you can place blame wherever. However when it is multiple different people for slightly different problems running it over several years, eventually you will get to the right branch.
- Zigurd 4y ago
  Management decision frameworks are often like that, but "5 Whys" is relatively innocuous - too simple to make tendentious. Mainly it is a reminder to dig until you hit bottom when doing root cause analysis.
tialaramex 4y ago
Not always. I read Accident Investigation reports for the transport industries in my countries. The vast majority of the time, management are a factor, for example the management of a bulk freighter haven't allowed enough crew for it to be operated safely, or the management of a airport haven't spent money on the improved hardware that would have prevented a dangerous incident. These reports inevitably have recommendations, many of which are directed to management. But once in a while it really isn't. My "favourite" was a fishing vessel which capsized killing everybody aboard. Why did it get into trouble? Because the entire crew were using heroin. That report has zero recommendations because there's nothing to recommend. It's already both illegal and obviously a bad idea to operate vessels at sea under the influence of drugs or alcohol, so there's nothing to recommend, those guys had only themselves to blame for their deaths.
- shuckles 4y ago
  You could say it's management's fault they didn't know entire crews were on heroin. This is one of the challenges of being management: every failure is conceivably a management problem.
  - tialaramex 4y ago
    What management? Small boat like that, everybody senior is likely a co-owner.
    - nobody9999 4y ago
      >What management? Small boat like that, everybody senior is likely a co-owner. And probably on the boat when it capsized and high on heroin too.

The flaw with 5 whys (not to say I don’t encourage it!) is they reflect the biases of the author while appearing unbiased and authoritative. So, it depends on who writes the post mortem who gets the blame.

travisjungroth 4y ago
Yes, because there’s insufficient room for reality. Causality is this big DAG with tons of incoming edges, going back to the beginning of time. 5 Whys is creating a path 5 edges long. This is often useful, but it’s not “the truth”. If each node has 10 incoming edges, there are 100,000 paths you could take. At least it’s better than root cause analysis, which is walking back until you want to stop and declaring that the root. The real root is the creation of the universe. I mean that sincerely. When you follow definitions of causality, time and the universe, you end up with the Big Bang as the root of your graph. Everything is else is editorializing.
- bentcorner 4y ago
  "In the beginning the Universe was created. This has made a lot of people very angry and has been widely regarded as a bad move."
- darkerside 4y ago
  To make an apple pie from scratch, you must first create the universe, as they say
AnimalMuppet 4y ago
A real 5 whys analysis probably should give a tree. Why did X happen? Because A, B, and C. Why did A happen? Because A1 and A2. And so on.
- drivers99 4y ago
  Fishbone diagram is one way to do that https://asq.org/quality-resources/fishbone https://asq.org/quality-resources/fishbone
- bluGill 4y ago
  You don't need to do that because there will be more 5-whys. Just pick whichever of A1, A2 seems like a bigger deal and find a B that seems like the biggest contribution - until you get to some deep root cause you can solve and mitigate. Then you fix that one issue and move one. You WILL see more issues, if they are always in other places you must have got the right one, if not then you will see this again and this time you can go down A2. The important part of the above is by refusing create the whole tree you actually get something solved. Sometimes you will get the right one, sometimes you won't. You can spend a lot of time building a tree of problems, and find tens of thousands of things you can fix - and now you have a larger todo list than you have time to do and likely you don't get anything done. Or analysis paralysis in other words.
  - fnordpiglet 4y ago
    This is specifically where bias comes in. People selectively prune the tree in ways that are either interesting (in a positive take) or deceptively based on their desire to avoid certain topics. Because the tree can be so large it isn’t always obvious even to the author whether they picked a branch because it was useful or because it served some other purpose - divert focus to a team they want to see behave differently, avoid taking blame for something, avoid being asked to fix something they don’t want to, etc. So, in this case the real question is “will they pick the branch that blames the people that pay and promote them, or take the branches that are of the least resistance.” Something this contentious would be vetted by committee in some way or another and at that point any upward finger pointing would be almost certainly curtailed in favor of a less contentious branch.
    - bluGill 4y ago
      Once again, there is only so many times you can keep re-running the same tree before someone will look for a different root cause. If you only run the process once you can place blame wherever. However when it is multiple different people for slightly different problems running it over several years, eventually you will get to the right branch.
Zigurd 4y ago
Management decision frameworks are often like that, but "5 Whys" is relatively innocuous - too simple to make tendentious. Mainly it is a reminder to dig until you hit bottom when doing root cause analysis.

tialaramex 4y ago

Not always. I read Accident Investigation reports for the transport industries in my countries. The vast majority of the time, management are a factor, for example the management of a bulk freighter haven't allowed enough crew for it to be operated safely, or the management of a airport haven't spent money on the improved hardware that would have prevented a dangerous incident. These reports inevitably have recommendations, many of which are directed to management. But once in a while it really isn't. My "favourite" was a fishing vessel which capsized killing everybody aboard. Why did it get into trouble? Because the entire crew were using heroin. That report has zero recommendations because there's nothing to recommend. It's already both illegal and obviously a bad idea to operate vessels at sea under the influence of drugs or alcohol, so there's nothing to recommend, those guys had only themselves to blame for their deaths.

shuckles 4y ago
You could say it's management's fault they didn't know entire crews were on heroin. This is one of the challenges of being management: every failure is conceivably a management problem.
- tialaramex 4y ago
  What management? Small boat like that, everybody senior is likely a co-owner.
  - nobody9999 4y ago
    >What management? Small boat like that, everybody senior is likely a co-owner. And probably on the boat when it capsized and high on heroin too.