Template

Root cause analysis template

After something went wrong: lay out exactly what happened, ask why until you reach causes you can change, and leave with fixes that each have an owner.

60 minutesFor Engineers, operations and support people who were involved, with a facilitator who was notAgenda room

Change the agenda first

The agenda, with a time for each part

What happened, in order10 min
- What did we see first, and when?
What we expected instead5 min
- What should have happened at each step?
Ask why, and keep asking20 min
- Why did that happen?
- And why was that possible?
Causes, not just triggers10 min
- Which of these, if fixed, would have stopped it happening at all?
Fixes, each with an owner15 min
- What do we change, who owns it, and by when?

How the notes read afterwards

A made-up example, so you can see the shape. In a real call each line carries the words that were said and who said them.

What happened. At 14:02 orders stopped saving; at 14:40 the database was restored.

Why. The disk filled. Why? Old logs were never deleted. Why? The clean-up job was switched off during a migration in May and never turned back on.

Cause. Nothing checks that scheduled jobs are still running.

Fixes. Alert when the disk passes 80% (Omar, this week). Alert when any scheduled job misses a run (Jess, by the 30th).

Running it well

Write the timeline before the meeting from logs and messages, so the hour is spent on why, not on remembering.
Ask why about the system, not the person. “Why could one command delete the table?” finds a fix; “why did Sam run it?” finds somebody to blame.
Stop asking why when you reach something you can change. Going further usually ends at “people make mistakes”, which nobody can fix.

Ways to change it

Thirty minutesFor a small problem: the timeline, three rounds of why, and one fix.

With a customer presentKeep the internal analysis separate; share the timeline, the cause and the fixes, in plain words.

When to skip it. For a one-off with no lasting cause — a typo fixed in a minute — note it and move on.

Questions

What is root cause analysis?

A structured look at a problem after it happens, to find the underlying causes that allowed it, rather than only the trigger, and to fix them.

What is the five whys method?

Asking “why?” about a problem, then about each answer, about five times, until you reach a cause you can change. It comes from Toyota's production system.

What is the difference between a root cause and a trigger?

The trigger is what set the problem off. The root cause is what allowed the trigger to do damage; fixing it stops the same kind of problem happening again.

What happens in the room

Everybody joins from the link, with no account. The agenda sits beside the call and each item fills in with what was said about it, under the name of the person who said it.

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