The summarised version: 1. Mistakes happen and will always happen. Saying "it wont happen again" doesn't fix the problem. 2. Make a joke to stop people getting defensive.
As much as I agree with the general message (nobody died, so it's not _that_ bad), and have employed that same technique over the years, the part about root cause is off point IMHO.<p>'Root cause' can absolutely refer to a collection of events. In the example given, clearly both things were causal, clearly you fix both - you don't pick one and label it 'THE root cause' and forget about the other (yes I know he talks about prioritisation, but again that's perfectly valid when addressing a root cause that happens to be a collection).
Brilliant, I've definitely struggled before with how to get people to 1)not worry about being blamed and 2)claim they won't repeat a mistake. This is totally actionable, thanks!
If you are interested in the root of this methodology, consider reading Toyota Production System by Taiichi Ohno. Page 17 starts the discussion on how asking Why Five times is a method of determining root cause. This book isn't popular, but is worth your time.<p><a href="http://www.amazon.com/Toyota-Production-System-Beyond-Large-Scale/dp/0915299143" rel="nofollow">http://www.amazon.com/Toyota-Production-System-Beyond-Large-...</a>
This is more a meta-comment about slideshare than about this presentation in particular. I really like being able to access the slides of talks I've seen, but for talks I haven't seen, there often is just enough that's missing from the slides that I don't get the full picture.<p>Does anybody have a solution to this?<p>Now, having said that, this particular slide deck suffers very little from this problem.