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    An important factor here is not to assign blame as blame ... does not seem that easy though unless there is a template format to achieve this.E.g. even in your answer the why's seem to lead to Bob or finger point at Bob
    – Jim
    Commented Sep 10, 2020 at 10:50
  • @Jim - I've expanded that section a bit. The answers did lead to Bob, but only after 2 'whys'. If you keep going you discover how the company can prevent the same thing happening again. Commented Sep 10, 2020 at 11:16
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    We have used the "5 why" technique and I found it to be of limited use. The results are very unstable and with a slight change on level 2/3 you will end up in completely different directions. For example, I might not question Bob's competence but ask "why has Bob to check it manually (as opposed to an automated test". Anyways, I found that in the end this will always end up somewere outside or at the border of the teams influence like staffing, the business strategy is changing every few months, a product that can do X was sold to solve problem Y, etc
    – Manziel
    Commented Sep 10, 2020 at 12:26
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    "An important factor here is not to assign blame" - but you just implied Bob was to blame! Commented Sep 10, 2020 at 18:26
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    I used to be a specialist in safety-related software. The main point to grasp there is that everyone gets stuff wrong. So asking "why did Bob build something wrong?" after the fact is the wrong question. The right question is "when Bob builds something wrong, who would spot it?" and then you can engineer your system so that two people have to screw up for the bug to leave the building.
    – Graham
    Commented Sep 11, 2020 at 0:28