- Was there another way to satisfy customer demand without balancing a rock on a hill?
- Must the rock balance on the hill, or just a hill? Must it be the rock or just a rock?
- What level of modifications would cause the hill to no longer count as the hill? What attributes would need to be transferred from the hill to another hill to make another hill count as the hill?
- Does the rock have to be made of this material? Does it have to be this shape?
- If the rock tumbles when no-one is looking, did it really tumble?
- What regulatory bodies are concerned with this rock balancing act? What are their opinions on our performance?
- Are records kept of our performance? Does it vary or is it constant? Is it acceptable? If not, why not? Who is responsible for this judgment, and who is responsible for ensuring our performance? What tools do they lack?
- What are the operating procedures of the balancing team? Are they followed? Why not? Does circumstances require not following procedures?
- Are people getting tired balancing? Why? Are there sufficient breaks? Why not? Do people need nutritious meals and are they getting it?
- Who is responsible for updating operating procedures based on operational experience? Are workers' opinions on improvements taken seriously?
- Are new people receiving sufficient training? Why not? Who is responsible for training? What qualified them for that?
- Does the culture value successful rock balancing? Does management? Is the motivation there? What are the levels of absenteeism? Why not? Why?
- Does communication between workers happen? Do they have a shared language? Are misunderstandings common? Why?
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There's just so many things that can (and do) go wrong, and so much that needs to be clarified in regards to how the system works that blindly strolling down a single "causal chain" is bordering on malpractice.
That point is, again, the attempt to get to root cause (whether you go deep or wide) is valuable. The idea that you won't get the ONE TRUE ANSWER shouldn't stop that effort. An organization that landed at either your or my answer is better off than one that landed at neither.
I strongly oppose that picture of failure.
Be sure to watch Richard Cook's video presentation linked on that page.
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If I had time, I'd type out the steps more explicitly, but important questions that an analysis process must raise:
- Why is this rock here to begin with? Did it need to be before? Does it need to be now?
- How far can we move it?
- What do we do to salvage the situation when it tumbles down?
- Why do we need people to hold it up? What other solutions were explored? Why were they rejected? Has the context changed?
- Why isn't there a system that monitors how well the rock is held up? Why do we not have systems that warn about faltering assumptions, like cliff slippiness?
- Can we make it cheaper to roll the rock back up?
Etc. These questions come up when you dig wider, not deeper. Any process that doesn't produce (and ideally answer) these questions is suboptimal.