As I described this weekend on Snapchat using the example of my house, Root Cause analysis – or asking the 5 why’s – is essential to lean scalability and a thriving culture of relentless improvement. In complex systems thinking, you must see problems (lack of quality, decreasing sales) as a symptom of the system as a whole.
I bought my first home in November in a north suburb of Chicago. Naturally, that means finding little issues here and there as I go. It was originally built in the 1950’s and I knew it was in a neighborhood that had flooded a bit a few years back. I was excited from the first tour to see a fantastic dual sump pump system in the finished basement.
Unfortunately: The previous homeowner had treated the symptom, not the problem.
A house (like a software product or tool in its context) is part of a complex adaptive system. It is inserted into a biological ecosystem, and integrated with multiple networks (cable, electrical, plumbing, roads). What the previous homeowner did is a mistake many of us make when it comes to eCommerce, marketing campaigns, enterprise software, you name it – the symptom was treated in the context of a system in homeostasis without changing the ability of the system to adapt to deal with a chaotic event.
SO – my basement has flooded, just a little, three times this spring.
Enter the “5 Why’s” Analysis:
1- Why is the carpet wet in the basement? The sump pump didn’t pump out the water quickly enough. If I were to continue to treat the symptom, I might upgrade the sump pump, which is expensive and might not work (and what we tend to do in the workplace).
2- Why didn’t the sump pump handle it? There was too much water around the house, building up hydrostatic pressure. The second time we had flooding, I noticed that the water appeared to have come in from all sides, not from the sump pump reservoir overflowing. (i.e. without “going to the place” I might have continued to blame the sump pump)
3- Why was there too much water around the foundation? I have a negative grade, meaning my lawn on one side slopes slightly toward the house. Again, easy to blame that and spend a fortune on a re-grading (legacy system migration anyone?) but I had the joy of really, really “going to the place” and spent an 1hr flash-flood storm OUTSIDE, managing the flow of water in non-normal conditions. After all, the yard may slope slightly, but there are 4 basement egresses with drains in the bottom that run to the sump pump…
4- Why did so much water flow to the basement window wells that the drains couldn’t get the water to the sump pump quickly enough? (notice that we are finally getting somewhere in our root cause analysis!) Once I was out in the storm, it was clear that the rain on its own was not the issue: despite having cleaned out my gutters hours before the storm, the winds that blew the storm in kicked lots of new leaves onto my roof, blocked the gutter, and a waterfall of water came off the gutter onto the negative grade instead of going down the downspout system that drains the water in a safer direction. What I also noticed was that the sidewalk gradually filled with water from the downspout nicely – meaning there was a certain amount of in-yard flooding that could occur before the water would pour unchecked into my window wells. (note, I could invest in LeafGuard or something as part of a total replacement of my gutters, but have we really found the root cause?)
5- Why doesn’t the system (my house in its context) handle a the flow of water in that quantity? Now we’re down to business. The soil has a high clay content and hasn’t been aerated recently. The previous homeowner removed bushes on that side of the house but not the roots and stumps. The downspouts eject water 3 feet from the house, but into an area of the lawn that can be easily filled with water that will then flow back to the egresses.
Root cause – The system is not prepared to handle the flow of unwanted inputs under non-normal conditions.
Oops, I slipped into discussing emergent leadership in complex adaptive systems. What I meant was, nobody had bothered to look at what happens to the flow of excess water in flash-flood conditions. Just like I frequently see no one planning for “storms” in their agile or devops culture, their social media presence, or omnichannel efforts.
To round out the story, now that we have a ROOT CAUSE. I can come up with a….
Solution – Create a sub-system that encourage adaptation to non-normal systemic conditions.
Sorry, I did it again. But you really can’t tack on a new tool or process if you have underlying cultural factors that need to be addressed. For my house, the answer is simple, add a French Drain system that will handle excess water during a flash flood.
Now, with my years in custom app development consulting, the parallel is really quite striking. Investment in a bigger pump, a total re-grading, or new and improved gutters would have been an expensive way to deal with emergent properties of the system without helping it adapt properly to non-normal stress. The french drain and dry well implementation I have started will require some hard work (i’m digging it by hand!) but potentially no cash (I already have more river stones than I know what to do with).