At three Why’s the branching factor is down low enough that a quick person can guess what many of them are and compare them with the lunch conversation and water cooler gripes and the capabilities of the team and steer toward something - anything - that is actionable and will materially reduce the class of problem - not just the same problem, but ones with any similarity.
I think that’s the best you can do, but it has problems. One, it becomes a bit of smoke and mirrors for people new to the process. Two, this only works for people who have access and recall of all the near misses and any grumbling in the ranks. Optimists cannot do a 5W justice. Three, I don’t trust any Five Why’s that I’m not present for, because there’s a moment in every RCA meeting where if I don’t judo throw the conversation we end up with some milquetoast bullshit fix that doesn’t fix anything or just makes things worse, and writing code more onerous.
I think that’s the best you can do, but it has problems. One, it becomes a bit of smoke and mirrors for people new to the process. Two, this only works for people who have access and recall of all the near misses and any grumbling in the ranks. Optimists cannot do a 5W justice. Three, I don’t trust any Five Why’s that I’m not present for, because there’s a moment in every RCA meeting where if I don’t judo throw the conversation we end up with some milquetoast bullshit fix that doesn’t fix anything or just makes things worse, and writing code more onerous.