The tech industry is badly re-inventing processes that the rest of the world developed decades ago. Other industries have learned to deal with far more complex and serious issues of quality. If there is arrogance in our approach, it's our failure to learn from other industries; lots of people in the tech industry have heard of the Five Whys, but very few have actually read Taiichi Ohno's Workplace Management, W. Edwards Deming's Out Of The Crisis or Walter A. Shewhart's Economic Control of Quality of Manufactured Product.
I frequently recommend this lecture on the Piper Alpha disaster, a fire on an offshore oil rig that killed 167 men. It eloquently summarises the findings of the Cullen Enquiry, a six month study of exactly why the disaster happened and what could be done to improve safety in the offshore industry. The enquiry found a complex and interconnected set of factors encompassing process, training, culture and design. It is densely packed with lessons that can be applied to our industry, not least of which is the idea of conducting intensive and systematic inquiries into major failures.
Thank you for this very considered response - I've enjoyed all of those books! There is a tendency to read secondary sources that are presented in a current consumable format. Rare is it that someone has read the primary sources or even referenced them. As a gentle introduction to the impact of engineering for quality, I give people copies James P. Womack and Daniel T. Jones's The Machine That Changed the World : The Story of Lean Production. If this leads to questions for further study, I point them to Ohno and Deming. As for the topic of this thread, Root Cause analysis is only one method of problem solving and other systemic methods may be more appropriate depending on the issue.
For a thorough and in-depth treatise on critical thinking and methods, one could read Problem Solving, Decision Making, and Professional Judgment by Paul Brest and Linda Hamilton Krieger. They provide examples of many decision making frameworks, cognitive biases, in a readable format.
I frequently recommend this lecture on the Piper Alpha disaster, a fire on an offshore oil rig that killed 167 men. It eloquently summarises the findings of the Cullen Enquiry, a six month study of exactly why the disaster happened and what could be done to improve safety in the offshore industry. The enquiry found a complex and interconnected set of factors encompassing process, training, culture and design. It is densely packed with lessons that can be applied to our industry, not least of which is the idea of conducting intensive and systematic inquiries into major failures.
https://www.youtube.com/watch?v=S9h8MKG88_U