What does this research mean for the field?

System design and architectural patterns targeting fundamental root causes are more successful than procedural governance at addressing organizational vulnerabilities. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This research aims to identify core vulnerabilities in organizational issue management using the CAR methodology.

May 20, 2026Open Access

Root Cause Analysis of Organizational IssueVulnerabilities Using CAR Methodology: Fishbone Diagrams and 5 Whys Analysis in Issue Management

Key Points

This research aims to identify core vulnerabilities in organizational issue management using the CAR methodology.
Employs Causal Analysis and Resolution (CAR) methodology;
Uses Fishbone Diagrams and the 5 Whys analysis;
Analyzes 4,847 issues from eight organizations.
Identifies six major vulnerability categories affecting organizations: workflows avoidance, knowledge loss, automated system failures, over-reliance on automation, gradual improvements, and rare issues.
Finds that addressing root causes via architectural patterns increases vulnerability incidence rates by 88%.
Proves that system design proves more effective than procedural governance.

Abstract

— Organizations at CMMI Level 5 claim advanced procedures, yet they nevertheless have chronic organizational weaknesses. This study employs the Causal Analysis and Resolution (CAR) approach, along with Fishbone Diagrams and the 5 Whys technique, to uncover the core causes of six vulnerability categories affecting organizational issue management. (1) People avoid workflows (32%, 1,551 difficulties). (2) Significant knowledge was lost (24%, 1,163 problems). (3) Automated systems fail (18%; 872 problems). (4) Over-reliance on automation (15%, 727 problems). (5) Improvements occur gradually (8%, 388 issues), and (6) Rare but serious issues (3%, 146 issues). We discover fundamental causes for each vulnerability category using systematic root cause analysis across five dimensions (People, Process, Technology, Data, and Methods). The Issue Management System (IMS) built with Spring Boot 3.3.2, React 18, and PostgreSQL offers architectural options for addressing identified root issues. Empirical examination of 4,847 issues from eight businesses shows that architectural patterns targeting fundamental causes increase vulnerability incidence rates by 88%, proving that system design is more successful than procedural governance.

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