The Root Cause Fallacy
Posted in Operations on Jul 21, 2014
Wouldn’t you like to find the root cause of that downtime incident? Many people would. But experience has taught me that there is no such thing as a single root cause. Instead, there’s a chain of interrelated causes, each of which is necessary but none of which is sufficient to cause the overall problem.
I am often reminded of an outage years ago. It was “caused” by a failed disk. But the disk was in a RAID5 array, and another disk in that array had failed some time previously. Backups had also failed some time previously, so there were no backups. Health checks didn’t notify anyone of the degraded disk array, due to a misconfigured alerting system. Alerting and backups failed because the person in charge of operations was not performing his duties. The operations person was still in the driver’s seat because of management dysfunction.
If you really want to get to the root cause of a problem, you need to use the Five Whys approach. I rarely do that because I already know where it ends. The CEO or equivalent is always the problem. It’s turtles all the way down (or up). Saying that the CEO is ultimately responsible is true but useless. The CEO is ultimately responsible for everything.
That’s why the search for a root cause is usually a witch-hunt in disguise, trying to find someone or something to blame. If you think there is really a single cause, you eventually must identify a single person. If you stop short of that, everyone knows the process was a farce. But blaming a person is also a farce. Everyone knows that someone’s being thrown under the bus and that wasn’t the real problem.
There are several solutions to this dilemma. One is to stop looking for a single root cause, and instead identify the system of conditions or dysfunctions that jointly caused the observed problem. This allows something constructive to come out of the postmortem, instead of inexorably bringing pressure to bear on a well-meaning person who will then be sacrificed to appease the false gods of reductionist blame-gaming.
Another is to change the culture and own failures as opportunities. Navigating this can be tricky. I’ve heard from more than one person who was fired from a workforce with a supposedly “blameless culture” policy after tripping over a booby-trap. I haven’t attended one yet, but I’ve heard that Dave Zwieback’s postmortem workshops are excellent.
More and more people I speak to are either doubtful or outright reject root-cause analysis these days. That’s a good thing. I used to be pressured for root-cause analysis years ago, and there was always an airtight and unspoken assumption that of course such a thing exists and is the right way to handle the aftermath of an incident. I’m happy the times are changing. These days, even some companies have stopped saying their tools or products can find root causes. Maybe this trend will allow us to replace the manifest failures of root-cause analysis with something more helpful.