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Root cause analysis: Difference between revisions
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*Why won’t my car start? – The battery is dead. | *Why won’t my car start? – The battery is dead. | ||
*Why is the battery dead? – The alternator doesn’t work. | *Why is the battery dead? – The alternator doesn’t work. | ||
*Why won’t the alternator work? | *Why won’t the alternator work? — The alternator belt has broken. | ||
*Why has the alternator belt broken? – The alternator belt was worn out and not replaced. | *Why has the alternator belt broken? – The alternator belt was worn out and not replaced. | ||
*Why was the alternator belt not replaced in time? – The vehicle was not maintained according to its recommended service schedule. | *Why was the alternator belt not replaced in time? – The vehicle was not maintained according to its recommended service schedule. | ||
Thus: the root cause is that you didn’t follow a [[second-order derivative]] [[process]]. Now if that seems a little implausible to you, you have at least ''me'' for company. Notice the industry here: to reduce | 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]]. | ||
{{sa}} | {{sa}} | ||