It is true that causal analysis (root cause analysis) can be helpful in debugging just about anything. But, it requires looking backwards, which people/organizations don’t really like to do, in my experience. “Who wants to focus on bad stuff? Just patch it and move forward.”
The article mentions chaos in support of causality, but it is most likely a dead end for root cause analysis.
For anyone interested, here are some free templates/examples for root cause analysis:
I'm sure you know this already but: The idea isn't so much backward looking but forward looking. "Why this won't happen again". What are we going to do in the future which prevents this, or at least makes it far less likely to recur ?
Because if we change nothing, it's going to happen again. That's how history got that reputation for repeating itself. But in order to prevent it, we need to understand the causual chain in order to break it.
For investigators whose work feeds into regulators it's a bit sadder because instead of "Why this won't happen again" the results are usually recommendations which, if followed, would prevent it happening again but you get used to them not being followed, so you're repeating yourself. "Why our previous advice would have prevented this from happening again".
Thanks for writing all that instead of me. I've heard the "we are not looking for someone to blame, just fix it" too many times. That sort of reasoning strikes me as protecting people's egos as if that's more important than not repeating the same thing over and over again. Both positions have merits, of course.
Comments
It is true that causal analysis (root cause analysis) can be helpful in debugging just about anything. But, it requires looking backwards, which people/organizations don’t really like to do, in my experience. “Who wants to focus on bad stuff? Just patch it and move forward.”
The article mentions chaos in support of causality, but it is most likely a dead end for root cause analysis.
For anyone interested, here are some free templates/examples for root cause analysis:
https://www.smartsheet.com/free-root-cause-analysis-template...
Edit: And here are a couple of additional resources (note that the author R. Cook of “How Complex Systems Fail” has recently passed away - https://twitter.com/lund_hfss/status/1568242140546744322 )
1. A past HN discussion on system failure:
https://news.ycombinator.com/item?id=25550685
2. “How Complex Systems Fail” by Dr. R. Cook
https://how.complexsystems.fail/
I'm sure you know this already but: The idea isn't so much backward looking but forward looking. "Why this won't happen again". What are we going to do in the future which prevents this, or at least makes it far less likely to recur ?
Because if we change nothing, it's going to happen again. That's how history got that reputation for repeating itself. But in order to prevent it, we need to understand the causual chain in order to break it.
For investigators whose work feeds into regulators it's a bit sadder because instead of "Why this won't happen again" the results are usually recommendations which, if followed, would prevent it happening again but you get used to them not being followed, so you're repeating yourself. "Why our previous advice would have prevented this from happening again".
Thanks for writing all that instead of me. I've heard the "we are not looking for someone to blame, just fix it" too many times. That sort of reasoning strikes me as protecting people's egos as if that's more important than not repeating the same thing over and over again. Both positions have merits, of course.