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Root cause analysis: Difference between revisions
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:''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> | :''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> | ||
===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. | |||
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]]. | |||
Notice the industry here: to reduce | |||
{{sa}} | {{sa}} | ||
*{{fieldguide}} | |||
*[[Toyota Production System]] and the [[seven wastes]] | *[[Toyota Production System]] and the [[seven wastes]] | ||
{{ref}} | |||