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Root cause analysis: Difference between revisions
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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. | {{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. | ||
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. | ||
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> | |||
Wikipedia gives the following, somewhat implausible example: | Wikipedia gives the following, somewhat implausible example: | ||