Blog
Practical writing on Root Cause Analysis — frameworks, reliability practices, and worked examples.
Ponte do Esqueleto: a 3-legged 5-Whys review of the Brazil rope-jump fatality
Most coverage stopped at the missing rope. A 3-legged 5-Whys shows the jurisdiction gap that made the fatality possible.
3-legged 5-Whys are now built into RCA Map
3-legged 5-Whys are now built into RCA Map. We burned a batch of cookies to show how the three legs work.
What is a 3-legged 5-Whys analysis? (with examples)
A single chain of 'why' explains the trigger and misses the disaster. A 3-legged 5-Whys runs three parallel chains — what failed, what let the warning slide, and what shaped the decision — so the fix lands on the system, not the symptom.
"Prove it will fail": the sentence that launched Challenger
The engineers had the data and the right answer the night before Challenger launched. A single flip in the burden of proof was enough to overrule them. How a go/no-go hold point quietly inverts under pressure — and how to catch it in your own organization.
How to run a 5-Whys session that doesn't derail
A founder-led, opinionated guide to running blameless 5-Whys sessions that produce real corrective actions instead of polite consensus.
Five whys behind the CrowdStrike outage: where the validator gap actually lived
A blameless 5-Whys incident review of the 2024-07-19 CrowdStrike Falcon outage using only public sources. The validator bug was the trigger; the architecture made it a disaster.
AI-Powered Root Cause Analysis: The Next Evolution in Problem Solving
What AI actually does well in RCA — pattern detection, prior-case recall, branch suggestion — and where it still has to defer to human judgment.
Tools for Root Cause Analysis: A Practical Guide
An opinionated tour of the most-used RCA tools — 5 Whys, Fishbone, process maps, fault trees, 8D, trend analysis — and which one to reach for first.
What is Root Cause Analysis?
Root Cause Analysis finds the policy or system choice that made a failure inevitable — not the person who happened to be in the room. A practitioner's intro.
