This article is itself an example of oversimplifying a complex process.
Five whys and the notion of a single root cause are both weak heuristics— but also almost no one sees them otherwise. People are generally smart, not stupid, and already understand that systems are complex.
Still, it is useful to ask “how did this problem come to be?” and “what can we do to improve our system?” Neither of which require or even encourage oversimplification.
For what it's worth, this is not my experience. My experience is that there's often an attempt to assign blame to a small component of the system. My sense is it is ultimately to reduce effort or embarrassment, to blame whatever can be "fixed" with less work or indictment of "higher level" components. So the littler or less well-integrated person or more minor policy gets blamed over management or administration, or core operating policies, or culture, because the latter are harder to change or involve more admission of fundamental problems that could cause reputational harm.
It's uncommon in my experience to acknowledge systemic problems or problems with very fundamental policies.
My only criticism of the piece is that sometimes you can identify a root cause, but it's at a very high level of generality and/or involves an error of omission, which is harder to identify than an error of commission. For example, a policy or protocol that isn't present that could be.
"There is often an attempt..." is completely compatible with my point. SOME people oversimplify. Other people are merely simplifying. Assigning blame is also a relative matter. Some people might claim that all the blame belongs in one place, while most would admit, under cross-examination, that not ALL belongs in any one place.
Of course blame follows the lines of ideology and self-interest. This is also not indicative of people being stupid and not understanding complexity-- because it's not a problem with understanding. It's a problem of damage control.
It's entirely rational to want to control damage!
Yes, it's uncommon to acknowledge systemic problems. My point is that educating people about such things won't help much, since lack of education is not to blame for this pattern. See what I did there?
Air accidents investigations somehow seem to result in increased safety, so something can work. First idea that comes to mind is that those reports point out multiple causes usually.
I think you are right that once the exercise becomes hunting for a scapegoat it's pointless.
However, it can be a way for everyone to understand the system better. The goal should be making each of the dominoes less likely to fall. Doing so can simplify rather than add complexity.
This article is itself an example of oversimplifying a complex process.
Five whys and the notion of a single root cause are both weak heuristics— but also almost no one sees them otherwise. People are generally smart, not stupid, and already understand that systems are complex.
Still, it is useful to ask “how did this problem come to be?” and “what can we do to improve our system?” Neither of which require or even encourage oversimplification.
> understand that systems are complex.
For what it's worth, this is not my experience. My experience is that there's often an attempt to assign blame to a small component of the system. My sense is it is ultimately to reduce effort or embarrassment, to blame whatever can be "fixed" with less work or indictment of "higher level" components. So the littler or less well-integrated person or more minor policy gets blamed over management or administration, or core operating policies, or culture, because the latter are harder to change or involve more admission of fundamental problems that could cause reputational harm.
It's uncommon in my experience to acknowledge systemic problems or problems with very fundamental policies.
My only criticism of the piece is that sometimes you can identify a root cause, but it's at a very high level of generality and/or involves an error of omission, which is harder to identify than an error of commission. For example, a policy or protocol that isn't present that could be.
"There is often an attempt..." is completely compatible with my point. SOME people oversimplify. Other people are merely simplifying. Assigning blame is also a relative matter. Some people might claim that all the blame belongs in one place, while most would admit, under cross-examination, that not ALL belongs in any one place.
Of course blame follows the lines of ideology and self-interest. This is also not indicative of people being stupid and not understanding complexity-- because it's not a problem with understanding. It's a problem of damage control.
It's entirely rational to want to control damage!
Yes, it's uncommon to acknowledge systemic problems. My point is that educating people about such things won't help much, since lack of education is not to blame for this pattern. See what I did there?
Air accidents investigations somehow seem to result in increased safety, so something can work. First idea that comes to mind is that those reports point out multiple causes usually.
I think you are right that once the exercise becomes hunting for a scapegoat it's pointless.
However, it can be a way for everyone to understand the system better. The goal should be making each of the dominoes less likely to fall. Doing so can simplify rather than add complexity.