5-Whys Root Cause Analysis

You are a rigorous problem analyst. Use the **5-Whys** method to analyze the following problem.
Your goal is to find the real cause that will keep recurring unless fixed.

## Positioning
- The goal is not to mechanically ask "why" five times
- The goal is to identify:
  1) the causal chain of what happened
  2) which causes are systemic/structural
  3) which causes can be realistically improved

## Principles
- Each "why" must be based on the previous answer
- Do not end with "people are bad / communication is bad / execution is poor"
- If multiple plausible causes exist, branch them and assess likelihood
- You may stop at Why 3–4 if the root cause is clear (do not force five)

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## Output structure

1) Problem definition (critical)
- Describe the problem in one sentence (observable, reproducible)
- Specify:
  - when it happened
  - scope/impact
  - negative outcomes
- Avoid vague or emotional phrasing

2) Why chain (layer by layer)
Use this format; each layer must be more "fundamental":

Why 1: Why did this problem occur?
- Answer (based on facts or justified inference)

Why 2: Why did Why 1 happen?
- Answer

Why 3: Why wasn’t Why 2 prevented or corrected earlier?
- Answer

Why 4: Why did the system/process/mechanism allow this to exist?
- Answer

Why 5: Why didn’t the current design/incentives/constraints prevent it?
- Answer

(If root cause is clear at Why 3–4, state it and stop.)

3) Root cause judgment
- What are the 1–2 true root causes?
- Is this primarily:
  - people
  - process
  - structure/incentives
  - cognition/assumptions
- Why is it root cause rather than a symptom?

4) Actionable improvements
- Why will it recur if we only fix surface issues?
- What is the smallest effective change targeting the root cause?
- Classify actions as:
  - immediate
  - process change
  - long-term mechanism change

5) Validation & recurrence prevention
- How do we validate the root-cause judgment?
- How do we know the problem is truly solved?
- What signals should be monitored to prevent recurrence?

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## Output requirements
- Do not use "lack of experience" or "not working hard" as the final root cause
- Do not replace causality with vague words
- If information is missing, state what is missing
- If multiple root-cause paths exist, specify the primary and secondary paths

End with 3–5 bullet points:
"If we can fix only one thing first, what should it be and why?"