Today, most AI work is based on neural networks, but back in the 1980s, AI researchers were using a different approach: they built rule-based systems using mathematical logic. This was the heyday of Lisp and Prolog, which were well-suited towards implementing these systems.
One approach AI researchers used was to sit down with an expert and elicit the rules they used to perform a task. For example, an AI researcher might conduct a series of interviews with a doctor in order to determine how the doctor diagnosed illnesses based on symptoms. The researcher would then encode those rules to build an expert system: a software package that would, ideally, perform tasks as well as an expert.
Alas, the results were disappointing: these expert systems never measured up to the performance of those human experts. Two brothers: Stuart Dreyfus (a professor of industrial engineering and operations research) and Hubert Dreyfus (a professor of philosophy) published a book in 1998 titled Mind Over Machine that described why this approach to building expert systems by eliciting and encoding rules from experts could never really work. It turns out that experts don’t actually solve problems by following a set of rules. Instead, they rely more on intuition and pattern-matching based on a repertoire of cases they’ve built up from their experience1.
Yet, even though those experts didn’t solve problems by following rules, they were still able to articulate a set of rules that they claim to follow when asked. And they weren’t trying to deceive the AI researchers. Instead, something else was going on. The experts were inventing explanations without even being aware that they were doing so. Philosophers of mind use the term confabulation (technically broad confabulation) to refer to this phenomenon: how people will unknowingly fabricate explanations for their actions.
And therein lies the problem of asking “why”.
In the wake of an incident, we often want to understand why it is people did certain things: both for the people whose actions contributed to the incident (why did they make a global configuration change?) and for people whose actions mitigated the incident (why did they suspect a retry storm rather than a DDOS attack?)
The problem is, you can’t just ask people why, because people confabulate. You can, of course, simply ask people why they took the actions they did. Heck, you might even get a confident, articulated explanation. But you shouldn’t believe that the explanation they give corresponds to reality.
Yet, getting at the why is important. This is not a case of “‘Why?’ is the wrong question“ the way that Five Whys style questions are. There is real value in understanding how people came to the decisions they did, by learning about the signals they received at the time, and how their previous experiences shaped their perspectives. That’s where having a skilled interviewer comes in.
A skilled interviewer will increase the chances of getting an accurate response by asking questions to bring the interviewee back into the frame of mind that they were in during the incident. Instead of asking for an engineer to explain their actions (Why did you do X?), they’ll ask questions to try to jog their memory of what they were experiencing during the incident: What were you doing when the page went off? Where did you look first? What did you see? And then what did you do? Because we know that experts do pattern-matching, they’ll also ask questions like, have you ever seen this symptom before? These questions can elicit responses about previous experiences they’ve had in similar situations, which can provide context on how they made their decisions in this case.
Eliciting this sort of information from an interview is hard, and it takes real skill. We should take this sort of work seriously.
1The field of research known as naturalistic decision making studies how experts make decisions.
Surfing Complexity 
Found this really useful in thinking about risk, assurance and safety generally. I think you might be interested in some research from a colleague at UQ who is looking at this in terms of where did the person get the knowledge from – implicit (first or second hand) or explicit – in coming to the decision to act. it adds another layer of information beyond just the decisions.