Five Whys: Lessons From the World of Incident Investigations

“If you do not ask the right question, you will not get the right answer.” — Olivier Serrat, “The Five Whys Technique

In the 21st century, cybersecurity is paramount to an organization’s survival. Yet many organizations have managed to get by with poor cybersecurity practices, which then only serves to reinforce the illusion that things are under control. Security leaders, C-suite executives and board directors tend to interpret near misses that go uninvestigated as evidence of the organization’s ability to successfully protect or react to security incidents.

Eventually, your luck will run out, disaster will strike, and none of your systems or processes will be able to save your data. You will be left wondering where things went wrong and why your layers of protective, detective and reactive controls didn’t put a stop to threats when there was still a chance.

Hold on to that inquisitive mindset: It could save your organization.

When Disaster Strikes

Why do disasters happen? What could we have done to prevent them? In his 2008 book “Outliers,” Malcolm Gladwell explored the lessons that can be drawn from studying aviation disasters, seeking to shed light on the root causes of some major crashes. The work, firmly grounded in the Federal Aviation Administration’s (FAA) Human Factors Analysis and Classification System (HFACS), pointed to the breakdown of communications inside the cockpit at key moments in the flight as a major source of human error, eventually leading to a perfect storm of factors contributing to a crash.

Yet airliners are built to very robust specifications and often have multiple resilient systems in case one fails. Similarly, today’s information technology systems and their accompanying security controls provide robust and fairly resilient systems that ensure the confidentiality, integrity and availability of data throughout the enterprise. Of course, having safety systems and resilience doesn’t completely eliminate the potential for disasters, much like having brakes on cars doesn’t remove the chance of a crash.

After an incident, it is tempting to blame someone, as was too often done in FAA crash investigations: “Unfortunately the root cause analysis of an accident often stops after the simple finding of ‘failure to follow procedures.’ This failure goes far beyond a ‘lazy mechanic’ who chooses to be noncompliant.”

What we need is a straightforward but effective technique to guide us to determine the root cause — not the person to blame — and thus identify elements that can be improved or tweaked to prevent future incidents.

The Five Whys

The Five Whys is a method of exploring cause-and-effect relationships. This technique can be used as part of a root-cause analysis to uncover ways to avoid future incidents. When applied to recent near misses, it can help prevent future events from turning into full-blown disasters.

The Five Whys technique helps investigators and analysts determine the root cause of a problem by repeatedly asking, “Why?” Investigators are cautioned to use deduction, to focus on processes and not behavior, to avoid jumping to conclusions, and to focus on causes, not symptoms.

Fast Company provided an example of the Five Whys technique in action:

  1. Why did the machine stop? (There was an overload and the fuse blew.)
  2. Why was there an overload? (The bearing was not sufficiently lubricated.)
  3. Why was it not lubricated sufficiently? (The lubrication pump was not pumping sufficiently.)
  4. Why was it not pumping sufficiently? (The shaft of the pump was worn and rattling.)
  5. Why was the shaft worn out? (There was no strainer attached and metal scrap got in.)

Ask the Right Questions

Don’t let a near miss go uninvestigated. After all, a near miss could become a serious incident if not for a lucky catch by a security control, a call from an attentive employee who remembered his or her security awareness training, or a smart decision by security leadership to learn as much as possible from previous incidents (or near incidents) and apply those lessons to the entire security apparatus.

While not without its flaws, the Five Whys technique can help foster a sound and systematic approach to investigating both incidents and near misses. It puts the organization on a path to continuous self-improvement and provides improved clarity about just how efficient its security controls truly are.

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Christophe Veltsos

InfoSec, Risk, and Privacy Strategist - Minnesota State University, Mankato

Chris Veltsos is a professor in the Department of Computer Information Science at Minnesota State University, Mankato where he regularly teaches Information Security and Information Warfare classes. Beyond the classroom, Chris is also very active in the security community, engaging with community groups and advising business leaders on how to best manage information security risks.