By Jon Bernardi

There has been a disturbing rise of injuries once thought to have been eradicated. Several federal and state agencies are considering legislation to address the very dangerous injuries from the gathering of liquid di-hydrogen oxide from certain unprotected hills and wells. Once upon time became the last straw, when siblings Jack and Jill fetched the ill-fated pail. Not only were crowns injured, but various homeopathic remedies were implemented with little consequence except to other participants, notably Jill.

What caused this unfortunate turn of events?

That question can be answered by building a Cause Map, a visual root cause analysis.  In the Cause Mapping process, the first step is to fill in an Outline with the background information for an issue as well as how the problem impacts the goals.  In this example, the aforementioned fetching impacts quite a number of goals: Safety as crowns were broken; environmental, the spilled di-hydrogen oxide; regulatory, child corporal punishment and child labor laws; customer service, no di-hydrogen oxide available for multiple purposes; production, the delay of supper; and labor, the time needed for medical attention.

Fortunately no property was lost as the well-made bucket survived intact.  Once we have filled out the Outline, the next step is to ask “why” questions to find the different causes that contributed to the problem being analyzed.

So why were they going up a hill? This presents us with a number of potential paths of exploration as to why the well was at the top of a hill. Even without knowing a detailed answer we know that a potential solution would be to get them hooked up an established di-hydrogen oxide system as soon as possible!

Why was there no protection? Broken crowns are a serious affair. This combined with the potential for other injuries from the fractious “tumbling down” incident leaves us to wonder how the well could be constructed in such a manner.

These are areas for further exploration. Even with the unanswered questions we are still able to propose several solutions to ensure that child labor laws are not ignored, hills are properly protected, and home remedies are carefully considered.

To view an Outline and a high level Cause Map for this issue, click on “Download PDF” above.