American office English treats careful analysis as a separate event.
deep dive — “an exhaustive investigation, study, or analysis of a question or topic.” It is recorded from 1986. It is usually put on the calendar: “Let’s do a deep dive on that next week.”
get to the bottom of it — find the real cause.
take a step back — stop working on the solution and look at the problem again.
what problem are we solving? — a question asked when a discussion has moved ahead of the problem.
In 2008 Eric Ries described how his startup analyzed problems. After each problem, a meeting was held, led by a designated “five whys master,” with everyone involved present. The results were emailed to the whole company and “should read like plain English.”
Ries wrote that over time teams get used to “the rhythm of five whys, and it becomes completely normal to make incremental investments.”
The 9/11 Commission was created by Congress on November 27, 2002, and published its final report on July 22, 2004. It found “four kinds of failures: in imagination, policy, capabilities, and management.”
One section is titled “Institutionalizing Imagination: The Case of Aircraft as Weapons.” The commission found that the intelligence agencies had not applied their own methods for analyzing surprise attacks to the threat of hijacked aircraft. It argued that such imagination had to be made routine.
The management researcher Paul Nutt of Ohio State University studied 356 decisions made by senior managers in the United States and Canada. His 1999 article was titled “Surprising but true: Half the decisions in organizations fail.” The managers considered more than one option in “less than 20 percent of their decisions.”
In a later study of more than 400 decisions, Nutt found that managers “identify a concern and latch upon the first remedy that they come across.” He added: “Managers seem to believe that concerns and solutions come in pairs.” When the first idea was adopted without investigation, failure was “four times more likely.”
Since 1996 the Joint Commission, which accredits American hospitals, has required “thorough and credible comprehensive systematic analyses (for example, root cause analyses)” after a sentinel event, a serious unexpected harm to a patient. The policy followed incidents at accredited hospitals in 1995, including the amputation of the wrong foot.
Twenty years later the field reviewed its own results. In 2015 the National Patient Safety Foundation proposed renaming the process “Root Cause Analysis and Action.” Reviewers found a “tendency to focus on weak solutions such as reminders, education, and training over stronger solutions.” Other studies “failed to demonstrate that the corrective actions drawn from RCAs have prevented” future harm.
In How We Think (1910), the philosopher John Dewey described “five logically distinct steps” of a complete act of thought: “(i) a felt difficulty; (ii) its location and definition; (iii) suggestion of possible solution; (iv) development by reasoning of the bearings of the suggestion; (v) further observation and experiment leading to its acceptance or rejection.”
Educators read the steps as “the five linear steps to doing science.” One science educator recalled that teachers referred to “the scientific method” “like it was a titled thing.” The National Research Council later called the idea of “a single scientific method of observation, hypothesis, deduction, and conclusion” “fundamentally wrong.”
American management courses often tell a story about a monument in Washington. Its stone is wearing away from harsh cleaning. The cleaning is needed because of bird droppings. The birds come to eat spiders, the spiders come to eat insects, and the insects are drawn by the lights at dusk. Change the lighting, and the problem is solved.
There was a real study. The insects at the Lincoln and Jefferson Memorials were midges, studied by the entomologist Don Messersmith. In early 1990 a six-week test turned the lights on an hour after sunset three nights a week, and the midges fell by 85 percent. In May 1990 a 50-pound block of marble fell from the memorial.
The lighting change was dropped after photographers complained. By September 1995 it was no longer under consideration. Both memorials were repaired instead, in a program that took more than five years and cost $25 million.
“If I had an hour to solve a problem I’d spend 55 minutes defining it” is widely credited to Albert Einstein. Quote Investigator found “no known substantive support” that he said it. The first known Einstein attribution appeared in 1973, about 18 years after his death.
The earliest evidence points to Robert J. Aley, a mathematician at Indiana University. A 1945 leaflet by a University of Michigan professor says Aley would “spend the first fifty minutes reading and studying the problem.” In 1966 a book for manufacturing managers credited an unnamed Yale professor.