Root Cause Analysis (RCA) becomes far more powerful when you combine Orgtology’s Hypothesis 2x—every organisational phenomenon has a concrete (algorithmic) side and an abstract (dynamic) side—with a 5W1H framing and the iterative 5-Why drill. This layered approach unearths both machine-like failures and human currents that drive or distort them.
1. Frame the Failure through Hypothesis 2x
Start with a crisp problem statement, for example: “Order fulfilment lead times spiked 35% last quarter.”
Then split your lens:
- Concrete (What/How): Which algorithm, rule or process step mis-executed? How did it fail—missing validation, coding bug, throughput constraint?
- Abstract (Who/Why): Which mindsets, incentives, or informal norms bent or bypassed that rule? Why did people choose expediency over protocol?
This dual frame prevents lopsided diagnoses—neither “fix the code and forget the culture” nor “rally the troops and ignore process gaps.”
2. Deepen the Inquiry with 5W1H & 5-Why Drills
For each interrogative—Who, What, When, Where, Why, How—ask “Why?” five times, alternating concrete and abstract perspectives. Here’s a template for Who; repeat for the other six:
WHO
- Initial: Which role bypassed the system check?
- Why 1 (Concrete): Why did that role see the check as unnecessary?
- Why 2 (Abstract): Why do they mistrust or resent that check?
- Why 3 (Concrete): Why was the check’s importance unclear in SOPs or training?
- Why 4 (Abstract): Why has feedback from past skips gone unaddressed (fear of blame, no feedback loop)?
- Why 5 (Hybrid): What deep-seated norm or structural gap let this cycle persist?
Repeat under What
- What rule was skipped?
- Why 1: …
…and through When, Where, Why, How.
Each chain yields a micro root-cause—some purely algorithmic, others purely cultural, most a hybrid.
3. Transform the Ishikawa into a 2X analysis:
Below are five illustrative “concrete ↔ abstract” cause‐and‐effect pairs you can drop into your 2X Ishikawa. Each show how a hard-data failure (C) is driven or concealed by a soft-system dynamic (A).
| Concrete | Abstract | Assumption: | |
| People | Skipped final quality inspection step. | Overemphasis on meeting daily throughput targets. | When line-operators know their bonuses hinge on output, they quietly omit the “slow” inspection task. |
| Methods | Outdated SOP still refers to a retired system module | Siloed hand-over: IT and Ops never review doc updates together | Because no one owns the cross-team review, documentation lags the live process. |
| Machines | ERP order-entry validation rule missing for backdated orders | Distrust in IT’s ability to fix false positives | When users see the system flagging harmless entries, they pressure IT to disable rules altogether. |
| Materials | Vendor delivered incorrect packaging specs | Weak supplier relationships—no routine performance reviews | Suppliers exploit lax oversight, knowing there’s little consequence for errors. |
| Environment | Narrow aisle layout causes repeated picking delays | Facility planning driven by cost-cutting, not flow efficiency | Because budget debates dominate, the warehouse team never pushes for a redesign that would speed up pick-and-pack. |
4. Build a 2x Fishbone Diagram
- Upper half bones (C) = concrete causes (missing SOP step, code bug).
- Bottom half bones (A) = abstract drivers (blame culture, silo incentives).
4. Prioritise with a 2x Impact Matrix
| Low Abstract | High Abstract | |
| Low Concrete | “Easy to fix” items | “Culture blockers” |
| High Concrete | “Process failures” | Critical tipping points |
Tackle Critical tipping points first—those causes that score high both in algorithmic severity and in human-system friction.
5. Design Dual-Mode Interventions
For each prioritized cause, pair your responses:
- Concrete fix (How): E.g., embed the missing validation in the digital workflow; tighten error-alert thresholds.
- Abstract fix (Why/Who): E.g., convene blame-free “near-miss” forums; coach leaders on psychological safety; revise incentive structures.
This two-pronged strategy ensures that algorithmic guardrails last and cultural shifts stick.
6. Monitor as a Cyber-Social System
Establish dual feedback loops:
- Concrete metrics: E.g., real-time dashboards on throughput times, error rates, exception counts.
- Abstract metrics: E.g., regular pulse surveys on trust, frequency of workarounds, cross-team collaboration scores.
Observe how improvements in one domain reinforce gains in the other—does stronger safety culture reduce process deviations? Does tighter process boost staff confidence?
Conclusion
By supercharging RCA with the 5W1H framing and the 5-Why technique, done within orgtology’s Hypothesis 2x, you will reveal both the machine-like failures and the human dynamics behind them. This integrated approach delivers richer insights and more durable solutions.
Learn More
To learn more about orgtology methods, through short courses or formal training, please visit the UNIORG website: http://uniorg.education
If you have a bachelor’s degree or equivalent qualification, and are interested in becoming a Certified Orgtologist, then consider the Certified Orgtologist Program, fully accredited by the International Orgtology Institute – https://uniorg.education/cop/
