دانلود کتاب فراتر از پنج چرا – تحلیل علت ریشه ای و تفکر سیستمی

For the past 10 years, I have been working with clients in relation to root cause analysis and systems thinking, and it’s time to provide an overview for a wider audience. Why might this be of value? 1. To clarify why specific problems can be hard to fix and why surprises can come from ‘out of the blue’ despite lots of efforts to the contrary; 2. To help you think through, when things don’t go to plan, how you might assess what any individuals involved did or did not do; put bluntly, should anyone take the blame? 3. To illustrate the benefits of moving beyond firefighting, addressing a few root causes now can head off many more problems in the future; 4. To give some suggestions to avoid things going off track in the first place. From the start, I want to recognise how easy it is to misunderstand root causes. For example, the iceberg was not the root cause of the Titanic tragedy. Root cause analysis involves resisting the desire to blame someone or something immediately. Thus, neither Captain Edward Smith nor Lookout Frederick Fleet were the root causes of the Titanic disaster, nor were the number of lifeboats. That said, I will illustrate the problems of a ‘no‐blame’ mindset. Root cause analysis helps us untangle the ‘what, where, when, how and who’ of a disaster or setback and helps us understand why it happened. I will share numerous real‐life accounts from executives and managers illustrating the ‘hairline cracks’ to look out for that can result in significant setbacks. Their stories challenge a lot of the received wisdom and urban myths about what separates success from failure. This book gives an overview of the essentials of root cause analysis (RCA henceforth) and systems thinking that should be of practical value. The essence of what I am aiming for is summed up in Illustration 0.1. The book has three main sections comprising 14 chapters and three optional appendices.