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Blame and the Fallacy of Root Cause Analysis


So it has finally happened, some dreadful disaster has befallen your organisation: all your systems are down, you've been hacked or some fatal flaw in your software has ruined your whole day. You can't change the past, you can change the future, but only by learning from what went wrong.

There are two common outcomes from such an experience: blame and Root Cause Analysis. This talk describes why both are wrong and both make future failure more likely.

This talk also shows a better way of investigating software disaster and a way of identifying problems before they get that far. At the end of the talk you will be more resilient in the face of complex software projects that fail!

The author has worked as a flying instructor, photojournalist, oilfield engineer, humanitarian worker and software engineer. He has witnessed numerous disasters (and may have even been complicit in some of them).


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