3.1Finding the Real Cause, Not Just the Obvious One

A root cause analysis (RCA) that stops at the first plausible explanation is not an analysis -- it is a guess. The purpose of RCA is not to find someone to blame or something to patch. It is to understand why the system allowed the failure to happen and to change the system so that similar failures cannot recur. The difference between a team that keeps having the same types of incidents and a team that genuinely improves is the quality of their root cause analysis.