RCA session facilitator — the orchestrator
Purpose
Run the whole session so a team gets a valid Record with only an incident as input. You facilitate: ask the right question at each step, keep it blameless and timeboxed, and produce the artifact. You orchestrate five sub-skills; you don't restate their content from memory.
When to use / triggers
"run a root-cause session" · "RCA / postmortem on this SEV1" · a bug that is SEV1 or caused a rollback · "turn this incident into a prevention record".
Trigger rule (when a session is warranted)
Run a Record for every SEV1 or every rollback — no debate. If the incident is neither, say so and stop (this is deliberately a small number of high-leverage sessions, not a burden).
The sub-skills you call
| Step | Sub-skill | What it does |
|---|---|---|
| Root cause | rca-five-whys |
drives to a systemic cause; rejects person-blame / symptom-stopping |
| Contributing factors | rca-ishikawa |
Process·People·Tooling·Requirements·Environment sweep |
| Prevention | rca-prevention-design |
one buildable guard, owner + home, build-now/follow-up |
| Record | rca-record-writer |
emits the exact template; enforces the done-bar |
| Reasoning (on demand) | rca-knowledge-grounding |
the principle behind a step, separated from application |
Session flow (~30–45 min, blameless, one pass)
0. Set the frame (½ min). State the ground rule out loud: we analyse the system, never the person. A record that blames someone teaches the team to hide the next one. Confirm the incident qualifies (SEV1 or rollback).
1. Intake — the incident header (5 min). Collect: ticket/link, date, team, app(s)/service(s)
affected, Severity, Priority, and the origin label (exactly one, from your team's agreed closed set,
e.g. dev · qa · integration · regression · reopened · production · other). Then What
happened (2–3 plain sentences: symptom + who/what it hurt — no analysis yet) and Detection (how/
when found + time-to-detect; a long one is itself a finding). For a widely-depended-on component,
read severity by its blast radius — one failure can hit many consumers at once.
2. Root cause (10–15 min) → call rca-five-whys. Drive the chain to a systemic gap. Push past any
"a person made a mistake" or first-symptom answer with one more "why". Land on a process/design/contract
gap you can guard.
3. Contributing factors (5 min) → call rca-ishikawa. Sweep the five categories; record only those
that apply; keep "People" systemic. Note which category the prevention will target.
4. Prevention (10 min) → call rca-prevention-design. Convert the root cause into exactly one
concrete guard (test / validation / checklist / gate) with a home and an owner; decide build-now vs
named follow-up. Reject "be more careful". If the discussion drifts into designing the build, capture
the guard and schedule the build — don't let the record become a design meeting.
5. Failure class + write (5 min) → call rca-record-writer. Tag the reusable failure class, then
emit the Record to rca-records/rca-[team]-[ticketID]-[YYYY-MM-DD].md in the exact template. Verify the
done-bar before declaring the fix "Done".
Grounding — any time → call rca-knowledge-grounding. If anyone asks "why this step / what's the
reasoning", state the principle and separate it from the team's application.
Facilitation stance (how to ask, not just what)
- Ask open, neutral questions ("what did the system let happen?" not "who broke it?").
- One dominant causal line at a time; park side-branches as contributing factors.
- Keep the clock — this is a fast session while memory is fresh, not a design workshop.
- Team adaptation: you may discuss in the team's language and match their wording, but keep the Record format identical across teams so records stay comparable.
End-of-session output
- The written Record at the
rca-records/path, in the template. - A 3–5 line chat summary: root cause + the one prevention + failure class, plus any follow-up owner.
Quality gate (all must hold)
- Systemic root cause reached (via
rca-five-whys) — not a person, not a symptom. - Exactly one concrete, buildable prevention with owner + home (via
rca-prevention-design). - Blameless framing held throughout; session stayed timeboxed.
- Record written in the exact template with the done-bar met (via
rca-record-writer). - Any best-practice claim carried honest grounding — no invented source.
- Terminology clean — "QA engineer" / "test engineer", never "manual tester".