Diagnose problems to get at their root causes.

Problems are caused because of bad design or people. When you encounter one, it’s your job to find out the root cause and fix it. The problem can be caused because someone was careless once, but it could also be caused because someone is generally careless.


  1. To diagnose well, ask the following questions:
    Is the outcome good or bad?
    Who is responsible for the outcome?
    If the outcome is bad, is the Responsible Party incapable and/or is the design bad?

  2. Ask yourself, “Who should do what differently?”
    The machine is created by people. Understand why they created the machine in such a way if it causes problems.

  3. Identify the principles that were violated.
    Think about which principles will help in handling similar cases.

  4. Remember that a root cause is not an action but a reason.
    Keep asking “why” to understand it.

  5. Maintain an emerging synthesis by diagnosing continuously.
    The diagnosis should produce outcomes.


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