Ask who owns the failure before who caused it

When something fails, the first question in most rooms is who did it. It feels natural. It is also the least useful question.

The better question is who owned the risk at that moment.

Cause and owner are different things

A technician installs a unit wrongly. The cause is the technician. But the unit was handed to service without a certified install. The gap is the handover, and nobody owned it.

Fix the person and the same failure returns with the next person. Fix the handover and it stops.

A simple test

For any failure, write down three names.

1. Who did the last step. 2. Who owned the risk at that point. 3. Who accepted the work before it moved on.

If the second and third names are blank, you have found the real problem.

What changes in the room

People stop defending themselves and start describing what they saw. You get better information in half the time.

Blame is a way of ending a meeting. Ownership is a way of ending a failure.