Beyond the Five Whys

A straightforward explanation of root cause analysis and systems thinking, illustrating, with real-world examples and first-hand accounts, why things can ‘slip through our fingers’ and what to do to reduce the chances of things going off track.

Beyond the Five Whys summarises, for the first time, many of the tried and tested ways of understanding problems using insights from aviation, high reliability organisations and a range of thought-provoking sources. The book provides readers with a clear and structured explanation how to analyse setbacks and head off problems in the first place. It will challenge much of the received wisdom, such as the idea there can be one root cause or that a person or bad culture could be a root cause.

Specific areas covered:

• Learn what root causes are, how they differ from immediate and contributing causes and why it’s so important to go beyond the Five Whys technique for root cause analysis.
• Recalibrate the way you think about things going wrong, incorporating insights from systems thinking, so you can be clearer what ‘cultural’ or systemic problems mean in practice.
• Learn about the eight principal ways things can slip through our fingers.
• Go beyond the blame game and firefighting to avoid the never ending cycle of repeating issues.
• Strengthen your ability to read the output of a ‘lessons learned’ or enquiry report.
• Get a fresh perspective, using these techniques, on why the Titanic tragedy turned out so badly, and understand the numerous parallels between what happened then and a range of recent setbacks we have seen, such as the Covid 19 pandemic.
• Consider the broader application of these techniques to some of the challenges we face in the 21^st century.

Beyond the Five Whys also contains supplemental guidance how to make improvements in an organisation. It is of value to business managers and those in specialist roles such as GRC, ESG, risk, compliance, quality, project management, H&S, IT, and internal audit roles.

Introduction ix

Section 1: A High-level Overview of RCA and Systems Thinking 1

Chapter 1: Critical Points Concerning Root Cause Analysis (RCA) 3

Chapter 2: The Fishbone Diagram and Eight Ways of Understanding Why 15

Chapter 3: Systems Thinking and Eight Ways to Understand Why, with Connections 23

Section 2: Eight Ways to Understand Why, With Connections 43

Chapter 4: Setting Appropriate Strategies, Goals, and Understanding Risks 45

Chapter 5: Having Timely, Accurate Data, Information and Communications 63

Chapter 6: Setting Appropriate Roles, Responsibilities, Accountabilities and Authorities 79

Chapter 7: Ensuring a Suitable Design 93

Chapter 8: Understanding and Accommodating External Factors 103

Chapter 9: Effective Building, Maintenance and Change 119

Chapter 10: Understanding and Adapting to ‘Human Factors’ 139

Chapter 11: Addressing Resources, Priorities and Dilemmas 167

Chapter 12: The Titanic Tragedy and Parallels with Modern Disasters 185

Section 3: Taking Action, Now and in the Future 215

Chapter 13: The Challenges with Action Planning 217

Chapter 14: Where Are We Now and Looking Ahead 229

Appendix A: Practical Advice on Action Planning 243

Appendix B: Practical Advice to Improve RCA in an Organisation 251

Appendix C: Practical Advice for Internal Audit and Others in an Audit or Inspection Role 267

Acknowledgements 287

Notes 289

Index 331

JAMES C. PATERSON is Director of Risk & Assurance Insights. He spent more than twenty years in a corporate career and was the Chief Audit Executive for the AstraZeneca group. Since then he has been consulting for more than a decade on a range of topics, increasingly focusing on Root Cause Analysis.

Why do some problems seem so difficult to fix, and why do others seem to come out of nowhere, without warning? Why do we spend so much time putting out fires instead of strategically planning to prevent issues from arising in the first place? Why can allocating blame get in the way of finding the underlying reasons things haven’t gone to plan? Why was the Titanic tragedy so bad and what lessons can we learn from it to this day?

For readers who are already familiar with root cause analysis (RCA), as well as for those who are new to this powerful way of thinking, Beyond the Five Whys: Root Cause Analysis and Systems Thinking offers advice on how to get to the heart of what causes incidents and setbacks to occur, and how to maximise the chances of things going right in the first place.

This book’s title refers to one of the most popular RCA techniques: the 5 whys method. Whilst it can provide some useful insights, it often leads us to miss the bigger picture. That’s why author James C. Paterson introduces the systems thinking approach to understanding root causes.

With systems thinking, we can step back to see the subtle factors that may be contributing to a problem and gain clarity as to why you can do 99% of the right things and still end up with a catastrophic set back. The book also explains why some??‘obvious’ solutions to problems don’t work and may even make things worse.

Beyond the Five Whys contains a range of contributions from managers who have experienced setbacks and who have been prepared, often for the first time, to provide an ‘inside story’ of what can go wrong and why.

The book also distils a lot of practical advice from public inquiries, medicine, aviation, quality management and other sources, so readers have, in one volume, the essentials regarding these often poorly understood topics.

This is a book to read if you are looking for a fresh perspective on why things don’t go to plan and why sometimes we see similar things going wrong repeatedly; and suggests how to plan for success with more confidence. It contains additional material for those working in organisations who want to upgrade their current approach to Root Cause??Analysis.

Praise for Beyond the Five Whys

“James uses a combination of real-life stories and best practice insights to present a practical approach to root cause analysis that will help shift your mindset to unleash the power of being more curious.”
—Damian Finio, CFO Phibro Animal Healthcare Corporation

“As the world becomes ever more complex and fast paced it is imperative that we become outstanding at learning from experience. Somehow, we must get beyond blame and shame when examining why things go wrong. Otherwise, we will just repeat, and probably make bigger mistakes.”
—Andrew Pal CEng, FIMechE (Leadership Coach and Organisation Consultant)

“James Paterson, a former Chief Audit Executive, tackles a topic of immense importance across all organizational sectors. The book also includes practical guidance from leaders in business, risk and audit.”
—Nancy Haig, CIA, CBA, CFE, CRISC, Principal - PIAC LLC

“Through clear explanations and real-world examples, readers will learn how to systematically identify root causes and develop effective solutions that address the underlying problems. This book is a valuable resource that professionals can read and start to apply to improve their problem-solving skills and make a positive impact within their organizations. Highly recommend!”
—Sandeep Das - Head of Internal Audit, St John Ambulance