RCA that stops too early
Classic root cause analysis dies at “human error” — the analysis equivalent of “it broke.” Human error is the beginning of the question, not the answer.
The five whys, continued
Why did the person skip the step? Because the step conflicted with their target. Why did the target win? Because targets are reviewed weekly and steps never. Now that is a root cause you can act on.
Roots live in systems and stories
A behavioral root is always reasonable — given the incentives, the history, and the story someone is running about what is safe. Fix the conditions, and the behavior stops being sensible.
The One Action: Take your last “human error” incident. Ask why twice more than feels comfortable.