| ▲ | jasode an hour ago | |
>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 17 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. | ||