In the [Cognitive Systems Engineering] terminology, it is more important to understand what a joint cognitive system (JCS) does and why it does it, than to explain how it does it. [emphasis in the original]Erik Hollnagel & David D. Woods, Joint Cognitive Systems: Foundations of Cognitive Systems Engineering, p22
In my previous post, I linked to a famous essay by John Allspaw: The Infinite Hows (or, the Dangers Of The Five Whys). The main thrust of Allspaw’s essay can be summed up in this five word excerpt:
“Why?” is the wrong question.
As illustrated by the quote from Hollnagel & Woods at the top of this post, it turns out that cognitive systems engineering (CSE) is very big on answering “why” questions. Allspaw’s perspective on incident analysis is deeply influenced by research from cognitive systems engineering. So what’s going on here?
It turns out that the CSE folks are asking different kinds of “why” questions than the root cause analysis (RCA) folks. The RCA folks ask why did this incident happen? The CSE folks ask why did the system adapt the sorts of behaviors that contributed to the incident?
Those questions may sound similar, but they start from opposite assumptions. The RCA folks start with the assumption that there’s some sort of flaw in the system, a vulnerability that was previously unknown, and then base their analysis on identifying what that vulnerability was.
The CSE folks, on the other hand, start with the assumption that behaviors exhibited by the system developed through adaptation to existing constraints. The “why” question here is “why is this behavior adaptive? What purpose does it serve in the system?” Then they base the analysis on identifying attributes of the system such as constraints and goal conflicts that would explain why this behavior is adaptive.
This is one of the reasons why the CSE folks are so interested in incidents to begin with: because it can expose these kinds of constraints and conflicts that are part of the context of a system. It’s similar to how psychologists use optical illusions to study the heuristics that the human visual system employs: you look at the circumstances under which a system fails to get some insight into how it normally functions as well as it does.
“Why” questions can be useful! But you’ve got to ask the right ones.