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5. Thinking > Root-Cause Analysis

Root-Cause Analysis

Note

Whole Team

We prevent mistakes by fixing our process.

When I hear about a serious mistake on my project, my natural reaction is to get angry or frustrated. I want to blame someone for screwing up.

Unfortunately, this response ignores the reality of Murphy’s Law. If something can go wrong, it will. People are, well, people. Everybody makes mistakes. I certainly do. Aggressively laying blame might cause people to hide their mistakes, or to try to pin them on others, but this dysfunctional behavior won’t actually prevent mistakes.

Instead of getting angry, I try to remember Norm Kerth’s Prime Directive: everybody is doing the best job they can given their abilities and knowledge (see Retrospectives” later in this chapter for the full text of the Prime Directive). Rather than blaming people, I blame the process. What is it about the way we work that allowed this mistake to happen? How can we change the way we work so that it’s harder for something to go wrong?


  

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