Part Two · Develop Expertise

Stop Asking Who Failed

Why almost every recurring problem is a system problem in disguise

In brief

Almost every recurring problem is a system problem in disguise. Drawing on Deming's Red Bead Experiment, the chapter separates events from patterns and gives a root cause discipline that stops the same fires from coming back.

What the chapter covers

The Red Beads
Management Work vs. Leadership Work
Events Are Symptoms. Patterns Are Structure.
Why Quick Fixes Fail Slowly
Root Cause Discipline
Pareto and the Art of Stopping
From Firefighting to Structural Improvement
The Question to Ask on Tuesday Morning

“The workers work in a system. The system is the responsibility of management. The workers are not responsible for its defects.” — W. Edwards Deming

Questions for your team

What problem has come back under different names at least three times?
When something goes wrong, is our first question who or what?
Which of our quick fixes is failing slowly?
Run the Five Whys on one recurring problem. Did the chain stop at a person or at a condition?

Field Guide Tool #8

The Root Cause Worksheet

A five-stage diagnostic for any recurring problem: name the pattern, run the Five Whys, classify the structural cause, assess impact and frequency, design the structural response.

Best used whenever the same type of problem recurs.

Go deeper

Out of the Crisis by W. Edwards Deming
The Fifth Discipline by Peter Senge
Thinking in Systems by Donella Meadows