in reply to Five Whys
Excellent comments, Eyes.
Now, I happen to work as a software consultant, so I usually wind up walking into either “active fires” or, more likely, “smoking ruins.”
The project has usually reached and passed its turning burning-point.
Heads have rolled, and the best people have quit.
So, one of the first things that I try to do is to look at the team’s work-flow organization, or lack thereof.
I usually recommend that organizations do retrospectives, although w-i-t-h-o-u-t swallowing the kool-aid of “five-whys.” Technicians need to see their work as the business does. But the business(!) also needs to better understand how the teams actually work.
I read a little e-book called Managing the Mechanism ... never seen it on a shelf ... that had a lot of influence on my thinking. The premise behind this book is that software is a self-directing, autonomous software automaton.