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# Root cause analysis
## Problem
- What happened, in one sentence
- When and where it was first seen
- Who or what it affected
## People
- Training or experience gaps
- Handovers that dropped information
## Process
- A step that was skipped or unclear
- An outcome nobody owned
## Tools
- Equipment or software that failed
- Inputs that were wrong or late
## Environment
- Deadline pressure
- Outside events
## Measurement
- Warning signs we missed
- Data we did not have
## Five whys
- Why did it happen
  - Why was that possible
    - Why was it not caught
      - Why did the check fail
        - Why did nobody own it
## Fix
- Change that removes the root cause
- Check that catches it next time
- Owner and date