By Will Killin
Reconstruct what happened
I would compare several occurrences. Record the trigger, decisions, information available, action taken and subsequent events. Late decisions could arise from unclear authority, missing information or disagreement about objectives. A repeated symptom does not establish a repeated cause.
Test competing explanations
Ask what would support or weaken each account. Documents and conversations can disagree without anyone acting in bad faith. Trace actual decisions through the process. “People need to communicate better” needs to become a specific, testable explanation before it can be a useful finding.
Check whether the previous fix happened
An illustrative governance change might introduce an approval forum while leaving authority unresolved. Meetings take place, but decisions still return to the same executive. Establish whether the change was implemented, whether people could use it and whether it addressed the proposed cause.
Match conclusions to evidence
Several conditions may reinforce one another. Avoid naming one root cause just to make the report tidy. Set out what is established and which next action would best distinguish competing explanations. A small reversible test may be more proportionate than a substantial investigation; missing records may limit either approach.
Read the relevant account of my previous work.
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