The goal of investigating incidents using a progressive exploration of questioning, a technique know as the 5 Whys , is to identify the root cause of an incident.
This approach looks at each failure as having a cause-and-effect relationship that impacts distinct parts of a process.
This approach works well when we are looking at sequential mechanical processes. It does not work when we are looking at organic processes that do not behave in distinct linear sequences.
Computer programs have become so complex that they behave more more living, organic systems.
Organic systems follow models akin to those in biology, where parts are not distinct pieces, but are interrelated responsibilities. Each of which much be whole, that is complete and good unto themselves. They are, in their core essence, Holonic.
To gain the insight we need to help systems become more resilient, often we need to first step back, not in. To step in means that we focus on smaller and smaller pieces, in search of that singular root cause. To step back, we begin to understand the systematic relationships in a process which, perhaps, might require us to reimagine how we understand the system itself.
A process that requires us to develop the self-transforming mind with an Autonoetic Conscousness akin to Kagen's Order 5 consciousness.
See Kegan Follows Piaget.
But we must accept that there is no singular understanding of an organic system. In a sense, it is unknowable it its entirety. Our understanding is contextual, that is, from the perspective of each responsibility within it.
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