I'm just rolling my eyes more now. 5 why's does not enforce a single pathway, and you don't have to stop at 5 anythings.
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Replying to @colmmacc @copyconstruct
if 5whys doesn't enforce a single pathway, or linearize, or come with assumptions about incidents having a root cause, or require you to ask exactly 5 times... is it even (Toyota/LMS) 5 Whys?pic.twitter.com/vHM3OFVLZ5
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If you're saying we should look holistically at multiple levels and layers of incidents and talk to people about how they experienced incidents and the rationale behind their actions at the time... I think we agree? In which case this is just a terminology issue?
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Replying to @jhscott @copyconstruct
I find it very hard to take seriously, almost to the point of seeing it as arguing in bad faith, that 5Y critics earnestly believe that any serious practitioner would blindly doctrinally apply any mechanism like that.
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Replying to @colmmacc @copyconstruct
I'm probably making my point poorly, that said I do generally agree with (warning, long) https://www.oreilly.com/ideas/the-infinite-hows … I'd say the key points are 1) "why" frequently leading to a counterfactual framing when reviewing human actions ("why did the on call not check the graph?)" (1/2)
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(2) "The reality is that there is no such thing as the cause, or primary cause or root cause" (this quote is from Dekker, but similar concept is in How Complex Systems Fail linked above)
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Replying to @jhscott @copyconstruct
More eye-rolling. The notion that the specific words "why"/"how" relates to "who"/"what" is sophomoric garbage. Tending to pin blame on people, rather than environments and systems, or being satisfied with shallow proximate explanations, are independent cultural phenomena.
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“Sophomoric garbage” and eye-rolling. Amazing.
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I’ll lay out my experience and thoughts on this topic with more detail and respect, so apologies for the short dismissiveness for now. I don’t think why/how matters, it’s what goes with it. I also think events and causes can be reconstructed to an underestimated degree.
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The dismissiveness on these topics and perspectives is something I’ve heard from others at Amazon, although I’m unsure if there is a connection there.
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I suspect there is a connection. Amazon values operational excellence very deeply, but we don't share a lot of our culture and lessons. It may be hubris on our part, but we also think we have a very strong record ...
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... at the same time, we see some advice that we've tried and seen fail, or criticisms of approaches we know work. I'm planning to share much more in an upcoming talk!
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I’d encourage the sharing of the actual details of incident analysis at Amazon, then. The “5 Whys”, in the end, is a method (however implemented) to collect data. We can debate the common/unique implementations of methods...
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