A little April Fool's RCA
The sun broke through, the Constable General surveyed the sordid scene and said, “The pieces are scattered, men are crying, women are sobbing, and children are running away. How could this have happened?” Humpty Dumpty was no more. She wanted to know the details, what caused this incident?
Outline the problem
To analyze this tragedy and answer her questions we need to do a root cause analysis and look at the system of causes underlying this event. To begin this inquiry, requires us to build a Cause Map to understand what happened. The first step is to use an outline to describe the issue.
With the help of the Constable General and her investigators, we see there are different views on the what the problem is, and we capture those in the first line of the outline – a fall, many pieces, no Humpty Dumpty, many sad things. But to begin our analysis, that is, break the issue into its component parts, we need to know what goals of the kingdom were impacted (!!).
Two main impacts stand out, the loss of Humpty Dumpty, and the labor costs incurred by the King as all his horses and all his men are brought forth to try to piece Humpty Back together, not to mention leaving the Kingdom defenseless!
Analyze the event
We will continue our analysis with a straightforward 5-Why map:
The Constable General and just about everyone knew that Humpty Dumpty thrived on pontification from on high, but Humpty did not realize it would be his undoing.
We now add further detail to get a better understanding of the causes that led up to the impact on two important Kingdom goals.
DOWNLOAD THE CAUSE MAP FOR HUMPTY DUMPTY'S FALL:
The Constable General noted several very serious infractions. She wondered, “Why was there no fall protection in place?? Why was Humpty unbalanced? How did he manage to get up on the wall in the first place? “
Now that we have a better understanding of why Humtpy met his demise, we can propose solutions to reduce this risk of this recurring.
- Install barriers to guard against other balanced (or unbalanced) Humpty’s from getting up on the wall
- Promulgate standards for fall protection.
- Oops, set-up proper government agency – Special Kingdom Office For Falls – SKOFF, the motto “If you need help, call us, and we will SKOFF at thee!”
- Ban pontification
- Put in place a requirement for wall design analysis.
We can see that a Cause Map can help us to propose several different possible solutions. Just consider that being on a wall can be fraught with danger.
At the end the Constable General added, “Remember - There are eight million stories in the naked city, this is one of them….”