Beyond the Five Whys – Root Cause Analysis and Systems Thinking

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.

Introduction ix 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