The Myth of the Root Cause and Why You Are Chasing the Wrong Thing

Every postmortem seems to have the same question at the top.
What was the root cause?

It sounds clean and decisive. A single answer. A single reason why the incident happened. Find it, fix it, and move on.

Reality is rarely that simple.

Incidents Are Never Caused by One Thing

Complex systems fail in complex ways. There is never just one cause. A so-called root cause is usually a symptom that finally tipped everything over.

A missed alert looks like the cause until you ask why the alert was missed.
A failed deploy looks like the cause until you ask why the deploy was risky.
A human mistake looks like the cause until you ask what made that mistake possible.

The deeper you look, the more factors you find.

The Problem with the Root Cause Mindset

When teams focus on a single root cause, three things happen.

1. They stop digging too soon
   Once a team finds something that looks like a cause, the investigation slows down. The systemic issues remain hidden.
2. They assign blame to individuals
   A single cause often points to a single person. This creates a culture of fear rather than a culture of learning.
3. They ignore patterns
   A one-time cause means there is nothing more to fix. Until the same issue comes back in a slightly different form.

Think Contributing Factors, Not Root Cause

The most useful postmortems look at an incident as the result of multiple contributing factors interacting over time.

Ask these questions:

• What signals were missed or ignored?
• What processes allowed the issue to grow?
• What knowledge or context was missing?
• What technical debt or cultural shortcuts set the stage for failure?

You will find five or ten factors, not one. Each factor is an opportunity to improve.

The Goal is Resilience, Not Blame

The purpose of an RCA is not to put a name next to a mistake. It is to make the system more resilient.

If an incident can only happen when five things align, your work is to break that alignment. That might mean automating checks, improving visibility, creating safer defaults, or making it easier for teams to spot weak signals before they turn into outages.

Fixing a single root cause does not change the system. Addressing contributing factors changes the way the system behaves.

How Tools Can Help

The volume of data around modern incidents is huge. Chat logs, Zoom calls, alerts, metrics and tickets all contain pieces of the story. No single person can hold all of it in their head.

This is where intelligent tools can help. A good system will:

• Collect data from Slack, PagerDuty, Zoom and other sources
• Organize it into a clear timeline
• Surface recurring patterns across incidents
• Help teams see the broader set of contributing factors

Automation can handle the collection so your team can focus on the learning.

A Better Way Forward

Stop asking for a root cause. Start asking for a system of causes. The truth is always more complex, and the fixes that matter are never just one fix.

The companies that learn fastest are the ones that look beyond the obvious. They see incidents not as a hunt for a culprit but as an opportunity to strengthen the system.

If you want to see what this looks like in practice, take a look at COEhub. It is built around one idea: incidents are teachers, and there is always more than one lesson.