- Why did [mistaken action] seem like the correct action at the time?
- Why was the problem not detected automatically?
- Why was the mistake caught late, not early?
- Why was the problem not fixed automatically?
- Why did this require manual intervention?
- Why did this require human detection?
- Were any of the contributing factors already known problems?
- Why were they not addressed earlier?
- Have we seen these in previous RCAs?
Created
February 8, 2021 16:46
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