Five Whys is an iterative root-cause analysis technique: start with a problem, ask why it happened, and narrow the explanation with each answer. It helps distinguish individual mistakes from failures of planning, training, or system design, while recognizing that some incidents have multiple causes. section 7.2.2
Use the questioning to examine:
- Whether the failure reflects inadequate training, a basic error, an unusual edge case, distraction, stress, or missed steps. section 7.2.2
- Whether safeguards, checks, additional reviews, or retraining could prevent recurrence. section 7.2.2
- Whether the explanation is too narrow when several causes contributed to the failure. section 7.2.2
Wrong production window
A system manager deleted production web servers after mistaking a production terminal for development. The investigation led to safeguards, including an unusually conspicuous color for production terminal windows, alongside incident documentation and rectification steps. section 7.2.2
