I think I’m pretty good at Five Whys, for two reasons. One, I have enough of a chess player’s mind where I can see at about the third Why that someone is steering us toward a toothless solution and steer us toward a better one.
But the other one is that blameless doesn’t mean we don’t talk about the person who fucked up. The entire point of the NTSB’s version of the process is to get pilots and ground crew to be vulnerable. To explain how they pushed the wrong button or signed off on a maintenance deferment or whatever. I was tired, I got asked tangential questions during a critical moment. I misinterpreted the text, etc.
I’m neurodivergent. I spend way too much of my day analyzing my errors. But the way my brain works on a Tuesday is the way everyone else’s works in the middle of a high stress situation. For me it still feels like a bad Tuesday. The tools and steps I build for keeping me from looking stupid also work for the team, once they give them a chance. And during Five Why’s I just have to say the quiet parts out loud, and I can speculate rather well on whether other people had similar experiences.
But the other one is that blameless doesn’t mean we don’t talk about the person who fucked up. The entire point of the NTSB’s version of the process is to get pilots and ground crew to be vulnerable. To explain how they pushed the wrong button or signed off on a maintenance deferment or whatever. I was tired, I got asked tangential questions during a critical moment. I misinterpreted the text, etc.
I’m neurodivergent. I spend way too much of my day analyzing my errors. But the way my brain works on a Tuesday is the way everyone else’s works in the middle of a high stress situation. For me it still feels like a bad Tuesday. The tools and steps I build for keeping me from looking stupid also work for the team, once they give them a chance. And during Five Why’s I just have to say the quiet parts out loud, and I can speculate rather well on whether other people had similar experiences.