This is a short talk I gave a while ago about how complex systems fail, and root cause analysis. Transcript is below.
Transcript
We’re going to talk about root causes today, but since I only have about 10 minutes, I wanted to start with some stories from a book I’m writing called Bedtime Stories To Put Your Children To Sleep Instantly And Also Yourself.
This first story is about leprechauns. Once upon a time, there was a company with a new employee, and one day the employee asked their manager “why does everyone suddenly get in their cars as soon as it stops raining?”.
The manager said “it’s not about when the rain stops. It’s about when the rainbow appears. Common sense tells us that rainbows are produced by a pot of gold left on the ground by a Leprechaun. Everyone knows this — just go ask your Irish ancestor from the 11th century. It’s in books and stuff. But anyway, so, whenever we see a rainbow our proceedure is to trace it back to its source and get the gold. And when we get enough gold, we can all quit our jobs and we won’t have to work anymore.”
The employee walked away from that conversation thinking: how come everyone’s still at work if they’ve been finding all these pots of gold? The end.
Now for a completed different story. Once upon a time, there was a software company with a new employee. And one day the employee asked their manager “why does everyone do root cause analysis after an incident?”
And the manager said “well, common sense tells us that every incident has a root cause. And everyone knows this — just ask people in the industry. It’s in books and stuff. But anyway, whenever we have an incident, our proceedure is to ask the five whys. Why?! Why?! Why?! Why?! Why?! Why did this happen to us?! And that allows us to trace the incident back to its root cause, so that we can eliminate it. And once we’ve eliminated all the root causes, we won’t have any incidents anymore.”
The employee walked away from this conversation thinking: how come we have so many incidents if we’ve been eliminating root causes this whole time? The end.
So thanks for listening to my stories. Book coming soon. Now I’ll get on with my talk: Leprechauns, Root Causes, And Other Fairy Tales.
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