The summarised version: 1. Mistakes happen and will always happen. Saying "it wont happen again" doesn't fix the problem. 2. Make a joke to stop people getting defensive.

3. Plan for a future in which we remain as stupid as we are today. 4. Pick broad fixes over root cause fixes.

It makes me wonder what the 5 whys are. :)

As much as I agree with the general message (nobody died, so it's not _that_ bad), and have employed that same technique over the years, the part about root cause is off point IMHO.

'Root cause' can absolutely refer to a collection of events. In the example given, clearly both things were causal, clearly you fix both - you don't pick one and label it 'THE root cause' and forget about the other (yes I know he talks about prioritisation, but again that's perfectly valid when addressing a root cause that happens to be a collection).

Heya, author of the slides here.

Re: 'root causes' -- I find the words somewhat important. Like, if you say you're looking for a root cause, then people tend to be in the sort of moral mindset, and have a harder time seeing it as a collection of contingent events.

Also, in the (truly amazing) "How Complex Systems Fail", he's pretty down on "root cause":

http://www.ctlab.org/documents/How%20Complex%20Systems%20Fai...

"7) Post-accident attribution accident to a ‘root cause’ is fundamentally wrong"

I'm with you on this one. Especially in an iterative context, there is zero value in looking for the true root cause.

The point of the exercise is to identify economical interventions that will get the system to produce better results. If you go much beyond that, people can get off into moral, analytical, or philosophical weeds and get lost.

As long as you do retrospectives and five-whys frequently, you can count on useful analytical depth to come over time. If an issue is really both important and subtle, it will crop up again. The next time you'll have another perspective, so it will be easier to find. And by waiting, you'll have avoided examining all the equally subtle but unimportant things.

Brilliant, I've definitely struggled before with how to get people to 1)not worry about being blamed and 2)claim they won't repeat a mistake. This is totally actionable, thanks!

If you are interested in the root of this methodology, consider reading Toyota Production System by Taiichi Ohno. Page 17 starts the discussion on how asking Why Five times is a method of determining root cause. This book isn't popular, but is worth your time.

http://www.amazon.com/Toyota-Production-System-Beyond-Large-...

This is more a meta-comment about slideshare than about this presentation in particular. I really like being able to access the slides of talks I've seen, but for talks I haven't seen, there often is just enough that's missing from the slides that I don't get the full picture.

Does anybody have a solution to this?

Now, having said that, this particular slide deck suffers very little from this problem.

(author of slides here): I actually took the slides I presented, went back and interleaved simple bullet point slides covering what I talked about.

Because I have that same problem -- if someone has nice visual slides, the Slideshare is often kind of useless.

This is also good relationship advice. The slides, I mean, not putting bullets in things.

Thanks for taking the time to share your wisdom. These are great slides.

You did a good job! These slides were very readable and easy to follow.

I could almost hear the presenter in my head as I read through the slides.

This was my very favorite talk from the Lean Startup conference. I hope they put up the video as well, which was excellent.

What if one's humor goes off wrong, which is often the case in these situations?

Great talk from LS conference. Thanks for sharing.