That's one of the central questions of the book. But my take is that there are a bunch of ways to answer a "why" question, some more useful than others.
One very common mode is to take a complex causal web, trace until you find a person of low status, and then yell at and/or punish said scapegoat. That desire to blame is a very human approach, but it a) isn't very effective in preventing the next problem, and b) prevents real systemic understanding by providing a false feeling of resolution.
So if we really want to figure out why the failure occurred and reduce the odds of it happening again, we need to give up blame and look at how systems create incentives and behaviors in the people caught up in them. Only if everybody feels a sense of personal safety do we have much chance of getting at what happened and discussing it calmly enough that we can come to real understandings and real solutions.
Thanks for the clarification. This sounds like an interesting book.
The phrasing used on the web site is "Post-accident attribution to a ‘root cause’ is fundamentally wrong." At first glance, it sounds like the author means there is no cause that can be found so you shouldn't try to determine the cause. First they clarify by saying there are many causes not just one. However, this phrasing made me scratch my head:
> The evaluations based on such reasoning as ‘root cause’ do not reflect a technical understanding of the nature of failure but rather the social, cultural need to blame specific, localized forces or events for outcomes.
I don't know what other organizations are like, but where I work, when we do a "root cause analysis," we aren't literally looking for a single cause, despite the name. The "root cause" is almost always that pieces a, b, and c came together in an unexpected way. I can definitely think of places where I worked where they were mostly out to place blame, though, and I guess that's what they were trying to caution against.
I think blame is one way it can go bad, but not the only one. The whole framing of a "root cause" is dangerous, in that it encourages people to look for exactly one thing, and then not look beyond it when they find it. It sounds like your organization does decently in that regard, but they're doing it in spite of the "root cause" frame.
One very common mode is to take a complex causal web, trace until you find a person of low status, and then yell at and/or punish said scapegoat. That desire to blame is a very human approach, but it a) isn't very effective in preventing the next problem, and b) prevents real systemic understanding by providing a false feeling of resolution.
So if we really want to figure out why the failure occurred and reduce the odds of it happening again, we need to give up blame and look at how systems create incentives and behaviors in the people caught up in them. Only if everybody feels a sense of personal safety do we have much chance of getting at what happened and discussing it calmly enough that we can come to real understandings and real solutions.