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How to Run a 5 Whys (with Humans, not Robots)

slideshare.net

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Re: How to Run a 5 Whys (with Humans, not Robots)

#4
This is more a meta-comment about slideshare than about this presentation in particular. I really like being able to access the slides of talks I've seen, but for talks I haven't seen, there often is just enough that's missing from the slides that I don't get the full picture.

Does anybody have a solution to this?

Now, having said that, this particular slide deck suffers very little from this problem.

Re: How to Run a 5 Whys (with Humans, not Robots)

#5
post #3

The summarised version: 1. Mistakes happen and will always happen. Saying "it wont happen again" doesn't fix the problem. 2. Make a joke to stop people getting defensive.

3. Plan for a future in which we remain as stupid as we are today. 4. Pick broad fixes over root cause fixes.

Re: How to Run a 5 Whys (with Humans, not Robots)

#6
post #4

This is more a meta-comment about slideshare than about this presentation in particular. I really like being able to access the slides of talks I've seen, but for talks I haven't seen, there often is just enough that's missing from the slides that I don't get the full picture. Does anybody have a solution to this? Now, having said that, this particular slide deck suffers very little from this problem.

I could almost hear the presenter in my head as I read through the slides.

Re: How to Run a 5 Whys (with Humans, not Robots)

#7
As much as I agree with the general message (nobody died, so it's not _that_ bad), and have employed that same technique over the years, the part about root cause is off point IMHO.

'Root cause' can absolutely refer to a collection of events. In the example given, clearly both things were causal, clearly you fix both - you don't pick one and label it 'THE root cause' and forget about the other (yes I know he talks about prioritisation, but again that's perfectly valid when addressing a root cause that happens to be a collection).

Re: How to Run a 5 Whys (with Humans, not Robots)

#8

As much as I agree with the general message (nobody died, so it's not _that_ bad), and have employed that same technique over the years, the part about root cause is off point IMHO. 'Root cause' can absolutely refer to a collection of events. In the example given, clearly both things were causal, clearly you fix both - you don't pick one and label it 'THE root cause' and forget about the other (yes I know he talks ab…

Heya, author of the slides here.

Re: 'root causes' -- I find the words somewhat important. Like, if you say you're looking for a root cause, then people tend to be in the sort of moral mindset, and have a harder time seeing it as a collection of contingent events.

Also, in the (truly amazing) "How Complex Systems Fail", he's pretty down on "root cause":

http://www.ctlab.org/documents/How%20Complex%20Systems%20Fai...

"7) Post-accident attribution accident to a ‘root cause’ is fundamentally wrong"

Re: How to Run a 5 Whys (with Humans, not Robots)

#9
post #4

This is more a meta-comment about slideshare than about this presentation in particular. I really like being able to access the slides of talks I've seen, but for talks I haven't seen, there often is just enough that's missing from the slides that I don't get the full picture. Does anybody have a solution to this? Now, having said that, this particular slide deck suffers very little from this problem.

(author of slides here): I actually took the slides I presented, went back and interleaved simple bullet point slides covering what I talked about.

Because I have that same problem -- if someone has nice visual slides, the Slideshare is often kind of useless.

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