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-{{g}}A management technique designed to systematically identify the cause of problems on an established manufacturing process. From the little I know about it, involves behaving like a five-year-old and asking the same question — “why?” over and over again.
+{{a|devil|
+[[File:Elephants and turtle.jpg|450px|thumb|center|A [[root cause]], yesterday]]
+}}A management technique designed to systematically identify the cause of problems on an established manufacturing process. From the little I know about it, involves behaving like a five-year-old and asking the same question — “why?” over and over again.
-This makes some sense in a production-line context, where there are defined inputs and outputs, and one has already reduced the world to a [[nomological machine]]. It works less well when you are a pioneer, fighting through jungle thickets, seeking the Indies via a western route, or rolling in your wagon train into the salted deserts of what is now, but wasn’t then, Utah.
+This makes some sense in a production-line context, where there are defined inputs and outputs, and one has already reduced the world to a [[nomological machine]]. These are [[Simple system|simple]] and [[complicated system]]s.
-Wikipedia gives the following, somewhat implausible example:
+It works less well when you are a pioneer, fighting through jungle thickets, seeking the Indies via a western route, or rolling in your wagon train into the salted deserts of what is now, but wasn’t then, Utah. These are complex systems. Accident investigation theory from {{author|Sidney Dekker}} has the following observation:
+:''We think there is something like ''the'' cause of a mishap (sometimes we call it the [[root cause]] or the [[primary cause]]), and if we look in the rubble hard enough, we will find it there. The reality is that there is no such thing as ''the'' cause, or [[primary cause]] or [[root cause]]. Cause is something we construct, not find.''<ref>{{fieldguide}}, 33.</ref>
-An example of a problem is: The vehicle will not start.
+===Example===
+Wikipedia gives the following, somewhat implausible example where the problem is that your car won’t start.
+*Why won’t my car start? – Because the battery is dead.
+*Why is the battery dead? – Because the alternator doesn’t work.
+*Why won’t the alternator work? — Because the alternator belt has broken.
+*Why has the alternator belt broken? – Because the alternator belt was worn out and not replaced.
+*Why was the alternator belt not replaced in time? – Because you didn’t maintain the car according to its recommended service schedule.
-*Why? – The battery is dead.
+Thus: the root cause of your problem is that ''you didn’t follow regulations, you naughty little squirrel''. [[Operator error]]; a failure to attend to a [[second-order derivative]] [[process]]. Now if that seems a little implausible to you, you have at least ''me'' for company. And, I think, {{author|Sidney Dekker}}. And {{author|Charles Perrow}}, were he still around. Notice the industry here: to reduce a problem to a ''fundamental breach of a [[process]]'': a [[heuristic]] or algorithm designed to defend against the intractable messiness of the universe, but which treats that universe like a super-complicated game of [[Go]].
-*Why? – The alternator doesn’t work.
-*Why? - The alternator belt has broken.
-*Why? – The alternator belt was worn out and not replaced.
-*Why? – The vehicle was not maintained according to the recommended service schedule. (the root cause!)
-Notice the industry here: to reduce all problems to a fundamental breach of a process: a heuristic or algorithm designed to defend against the intractable messiness of the universe.
 {{sa}}
+*{{fieldguide}}
 *[[Toyota Production System]] and the [[seven wastes]]
+{{ref}}