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tptacek 2 hours ago

I'm a broken record on how important I think this document is, and that it's hard to appreciate it until you've had extended experience with complex systems actually failing.

The most commonly cited subtext or thrust of it is that "root cause analysis", at least on complex systems, is a fools errand. Something goes wrong, say, in a distributed lock system, and your whole deployment system enters a metastable failure state. Naturally, the "root cause" seems like lock system resiliency. But definitionally a metastable failure is one that persists after the inciting condition is resolved. Now you have two "root causes", the lock failure and the metastability of the deployment system fault. Keep looking and you'll find more.

But to me the biggest brick to the forehead in this piece is further observation that random things are failing all the time in any complex system. "Complex systems run in degraded mode". Resilient components are good, but it's the resiliency of the overall process that orchestrates the whole system that determines whether things are going to blow up.

All practitioner actions are gambles. I should have that inked somewhere.

jasode an hour ago | parent | next [-]

>The most commonly cited subtext or thrust of it is that "root cause analysis", at least on complex systems, is a fools errand.

It's only an issue when people take that phrase very literally. People have common sense to understand that things have multiple causes and a chain of events. NASA has "Root Cause Analysis" (singular) all over various official documentation and it doesn't stop them from understanding that the failed O-rings were not the single root cause of the Challenger explosion. Another cause was management normalizing the deviations of previous unsafe datapoints of prior launches which let them greenlight the launch in freezing temperatures. Another cause was the unrealistic flight schedules which can subconsciously pressure management into normalizing dangerous deviations. It wasn't The Rogers Commission that found the multiple causes; it was NASA engineers and management themselves explaining the multiple causes as they were interviewed by the Rogers Commission members.

For whatever reason, alternative jargon such as "Root Causes Analysis" (plural) or "Proximate and Distal Causes Analysis" isn't as widely used.

jonahx 18 minutes ago | parent [-]

> Another cause was the unrealistic flight schedules which can subconsciously pressure management into normalizing dangerous deviations.

In the case of Challenger, I think it's pretty clear this was the "root cause":

> According to testimony by Kilminster and Boisjoly, Mason finally turned to Bob Lund and said, "Take off your engineering hat and put on your management hat." Joe Kilminster wrote out the new recommendation and went back on line with the teleconference.

> The new recommendation stated that the cold was still a safety concern, but their people had found that the original data was indeed inconclusive and their "engineering assessment" was that launch was recommended, even though the engineers had no part in writing the new recommendation and refused to sign it.

-- https://onlineethics.virginia.edu/cases/engineering-ethics-c...

If you want to take the "system" view here, as is often the case, it is the organizational power structure and incentives therein that comprise the dangerous system. You had engineering experts easily predicting the disaster, but they had no decision making power. That was the problem. But if you set up an organization like that, where the egos of "get it done" managers are allowed to gamble with other people's lives to win their own accolades, the system is doomed from the start.

pdonis an hour ago | parent | prev | next [-]

> "root cause analysis", at least on complex systems, is a fools errand.

Not when properly understood--which, to be fair, it often isn't. The proper purpose of root cause analysis is to answer the question: does this failure mean I need to change something about this system? If the answer turns out to be yes, the thing that you need to change gets called the "root cause" of the failure. Of course that's a misnomer, strictly speaking, but that doesn't mean you answered the actual question wrong.

DrewADesign an hour ago | parent [-]

I don’t blame people for being confused about the term in software — it’s a bit more straightforward in manufacturing, for example.

That said, if you look at a system that failed and determine a root cause analysis is pointless, you may have just stumbled upon your root cause.

YZF 2 hours ago | parent | prev | next [-]

Root Cause Analysis is an organizational ritual that makes people feel like they're doing something. It's more about politics than about engineering. Not only is the process not useful- more often than not the correct root cause isn't even correctly identified.

Basically a poorly designed system is going to fail somewhere. I like to think about it either as the part of the iceberg that's visible or my other analogy is lighting doesn't strike twice at the same place. A robust/well designed system is just very different than a brittle/poorly designed system. The brittle system will exhibit random failures and trying to chase them is counterproductive.

We do have systems that are fairly complex and reliable. Take an internal combustion engine as one example or an entire car or an airplane (well, one of the well designed ones). Then we build bigger systems on top of that, a city's transportation system, where we do get to scales where things "fail" all the time. Yes, some bus somewhere or some train somewhere doesn't get to a station at the correct time, because a bus breaks down or heavy traffic or whatnot. But still a well designed system is robust to those. The parts we build the systems out of are well understood and so the resulting reliability can also be understood.

With software specifically we tend to not design and build that well. We throw stuff together. Then we're surprised when they fail. And we make excuses by saying "complex systems". I often feel it's our lack of discipline and skill vs. other domains and not really that our systems are that much more complex.

EDIT: Some might argue that mechanical systems like engines are just fundamentally simpler than software. But look at something like a bearing. Just one bearing is an incredibly complex system. Bearing failure is a statistical event, some bearings fail sooner, some fail later. There are centuries of know-how in the bearings used in said engine. Mechanical engineers generally use well understood components/designs and build in margin to meet the requirements of the engine they're designing. In software we often re-invent the "bearing" or we'll pick some new unproven design for a "bearing" and we'll generally build without a good understanding of the performance or failure modes of our "bearings" and without a known pattern as to how to use them and when to use them. And then we're surprised when our "car" fails in weird ways. We also don't test to the same standard that a mechanical engineer would use for a new design. They would have a room full of widgets doing ten million cycles before they accept the design as part of a larger system. We "yolo" it...

_boffin_ an hour ago | parent | prev | next [-]

Check out the book called, The Logic of Failure. I think you’ll like it

ErroneousBosh 2 hours ago | parent | prev [-]

> I'm a broken record on how important I think this document is, and that it's hard to appreciate it until you've had extended experience with complex systems actually failing.

If you want a bit of cheese to go with that wine, this article pairs nicely with The Grug-Brained Developer: https://grugbrain.dev/

tptacek 2 hours ago | parent [-]

I am also a broken record about Grug-brainedness, but I don't need to be so repetitive about it because so many other people are too.

ErroneousBosh an hour ago | parent [-]

My Grug-brained hill to die on is that there are many pieces of technology like the LM741 opamp, the Rover V8, Morris A-series and Peugeot XUD engines, and a big SQL database running on a thumping great Unix box, that have remained essentially unchanged for decades, worked well when they were new, and are still a perfectly good solution today for so much of what you want to do.

You know what they have in common? A lack of complexity. Lovely simple technology, fix it with a hammer. Drive it to the moon and back. Drive it across the desert. Bring tools though!