Root cause analysis, sometimes known as the 5 Whys, has been seen as a panacea or as a failure depending on how it’s used. One frequent problem with root cause analysis is that it is used to support a blame culture. Once we’ve found the person at the root of the problem (the one that made the ‘mistake’) and know who to blame we can proceed with a clear conscience.
However, taking a look at a better approach that gets beyond blame we pick up a sociotechnical lens to build a better approach to finding causal mechanisms. In doing so we find that the causation may be in the beliefs (mental models) we hold, which might be the beliefs that influence our organisational culture.