action #136007
## Observation
See #134282
## Acceptance criteria
* **AC1:** A [Five-Whys](https://en.wikipedia.org/wiki/Five_whys) analysis has been conducted and results documented
* **AC2:** Improvements are planned
## Suggestions
* Bring up in retro
* Conduct "Five-Whys" analysis for the topic
* Identify follow-up tasks in tickets
* Organize a call to conduct the 5 whys (not as part of the retro)