Complex systems are interconnected. When an incident occurs it isn’t triggered by one single event, but rather a series of events leading up to that one failure. Yet teams employ root cause analysis (RCA) as the primary means to identify one ultimate, sufficient cause. In this session, Robert Blumen discusses the idea that it’s not the single root cause, but rather the series of events that should be more closely examined. He reviews why humans are cognitively drawn to RCA, research and examples on event analysis, and proposes it’s the “how” not the “why” we should explore when systems fail.