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
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 21st 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.
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.
