Dragon Diagram – A powerful metaphor for team based
problem solving
Prashant Nasery, Projects & Quality Manager-UAE & Oman, The Kanoo Group,
P.O. Box 290, Dubai. Phone: +971-4-5072343, E-mail: naseryp@gmail.com
Dragon diagram - a tool for team based
problem solving offers many advantages
over traditional problem solving tools, such
as Fishbone Diagram and 5 Why analysis.
These advantages include:
 More holistic and deeper understanding
of a problem
 Use of an empowering, stimulating and
vivid metaphor
 Helps identify the paradigm at the root
of the problem and the opportunity for
innovation.
Keywords: Dragon, Fishbone, Problem
solving, FMEA, TRIZ
Abstract:
Dragon diagram - a tool for team based
problem solving - offers many advantages
over traditional tools such as “Fishbone
Diagram” and “5 Why analysis”.
It uses an improved metaphor for problem
solving that includes a fire breathing
dragon, which is a pet of a wicked villain,
who has imprisoned a beautiful princess.
The members of the problem solving team
are the heroes, whose objective is to slay
the dragon to free the princess.
This metaphor holistically represents all
aspects of a problem, i.e. the consequences,
causes, the underlying systemic constraints
and hidden innovation opportunities
integrating concepts from a number of
methodologies including FMEA (Failure
Modes & Effects Analysis, TRIZ (Theory of
Inventive Problem Solving and TOC
(Theory of Constraints).
Apart from being more informative and
holistic in describing a problem, this
metaphor is more interesting, empowering
and engages the teams with greater
enthusiasm. Problem solving teams in two
different organizations, who used this tool,
found it to be very engaging, empowering
and effective.
ARTICLE:
Dr. Kaoru Ishikawa, who is also known as
the “father of QC Circles movement” in
Japan, developed a set of simple tools, the
Seven QC tools to encourage and involve
teams of workers in solving problems in
production processes to improve quality and
productivity.
Cause and Effect Diagram is one of the
most popularly used tools out of the Seven
QC Tools. It is also known as “Ishikawa
Diagram” in recognition of Dr. Ishikawa’s
efforts in popularizing it. Cause and Effect
diagram is based on the premise that a
problem is a result or output of a process
and there are multiple factors in the process
that affect the output. All the factors can be
grouped in usually 4 to 6 groups and within
those groups the factors can be arranged
according to their causal relationships. Thus
like small streams joining together to form
small rivulets which in turn join a large
river, the sub-factors and main factors join
together to cause the problem1.
In order to explain this concept Dr.
Ishikawa used a metaphor of a fish, which is
a very familiar object to most people around
the world. He likened the problem to the
head of the fish; the major lateral bones,
which are attached to the central bone, to
the main factors in the process and the
Figure-1 Fishbone Diagram (Cause & Effect or Ishikawa Diagram)
Measure-
ment Machine
Maintenance
Calibration
Design
Attachments
Centerin
Fixing
g
Dust
Cutting
spee
Environ Method d Materials
ment
Causal factors and Sub-factors
Fishbone diagram essentially is a
brainstorming tool which is best used by a
team of people who are involved in the
process and who have knowledge of its
various aspects. The team includes most
importantly the workers or operators who
are closest to the process and also the
process engineers, QC inspectors,
maintenance engineers, etc. who have the
requisite technical knowledge of the
equipment.
Thus a cross-functional team uses Fishbone
diagram to identify all possible causal
factors and to logically group them into
categories and sub-categories showing their
interrelationships. Later these factors are
critically reviewed and validated by seeking
evidence of their actual existence and
smaller bones to the sub-factors. (See
Figure-1). Therefore this tool also became
to be known as “Fish Bone Diagram”.
Man
Training
Morale
Problem
Tool
Rough
Job surface
Surfac
e
Hardnes
s
Effect
significance by way of one or more of the
following methods:
 Logical reasoning and use of
experience
 Physical verification of actual
condition in the process2
 Simulation of problem
 Data collection and analysis
The idea is to prioritise the causes in terms
of their significance to the problem and then
tackle them one by one. This method is
based on the typical reductionism approach3
which is the backbone of scientific thinking.
In this approach a problem or phenomenon
is broken down in its component parts and
each part is then examined to learn and
develop better understanding about it. This
is a typical “left brain” approach based on
logical, sequential thinking. Roger Sperry
(1973) ) who proposed the theory of the
right and left brains and won a Nobel Prize
in 1981 for this discovery, postulated that
left and right parts of human brain have
Figure-2 Left Brain versus Right Brain
LEFT BRAIN
Uses logic
Detail oriented
Facts rule
Words and language
Math and science
Can comprehend
Knowledge
Order/pattern perception
Reality based
Forms strategies
Practical
Safe
The right brain is actually much more
powerful and creative than the left brain;
however it is not well structured. According
to Roger Sperry (1973):
“The main theme to emerge... is that there
appear to be two modes of thinking, verbal
and nonverbal, represented rather
separately in left and right hemispheres
respectively and that our education system,
as well as science in general, tends to
neglect the nonverbal form of intellect.
What it comes down to is that modern
society discriminates against the right
hemisphere.
-Roger Sperry (1973)
Experts agree that a harnessing the power of
left and right parts of brain together makes
thinking highly effective.
Tony Buzan’s (2000) Mind Mapping tool4,
which is akin to Fishbone diagram, utilizes
the right brain approach to describe a
problem or an issue by drawing a colourful
different functions. Whereas the left part of
the brain thinks in terms of logic, sequence,
rules, etc., the right brain thinks in terms of
pictures, metaphors, stories etc. (Refer
Figure-2).
RIGHT BRAIN
Uses feeling
"Big Picture" oriented
Imagination rules
Symbols and images
Philosophy & religion
Can "get it" (i.e. meaning)
Beliefs
Spatial perception
Fantasy based
Presents possibilities
Impetuous
Risk taking
pictorial diagram, in which a core idea is
split into main ideas which are further split
into sub-ideas and so on.
Metaphorical Thinking:
The power of metaphors in creative
problem solving is very well recognized in
Systems Thinking discipline. Michael
Jackson and Robert Flood (1991)5 have
emphasized the importance of metaphors in
creative problem solving in their theory of
Total Systems Intervention (TSI).
According to them, thinking in terms of
metaphors helps engage the participants and
uncover important but vague ideas which
are difficult to express in words. Peter
Checkland’s Soft Systems Methodology6
makes use of “Rich Picture” as a tool to
express the vague complex cultural and
political elements in an organizational
situation that needs to be improved.
According to Russell Ackoff (1981)7, a
proponent of Systems Thinking and
Idealized Planning, a problem can be
resolved, solved or dissolved. It means that
when there is a problem, one can mitigate
its effect (resolve) or find and eliminate its
root cause (solve). However, one can also
make such a change in the overall system
that the question of the problem arising
itself does not arise. For example, throwing
away paper plates and plastic cutlery after
eating a picnic snack causes littering and
harm to environment. One could resolve the
problem by enforcing strict fines for
littering or could solve the problem by
finding root cause(s) such as inadequate
number and inconvenient placement of trash
bins, lack of education of people etc. and by
remedying them. The problem could be
dissolved if one could make edible plates
and cutlery at a reasonable cost, which
people could eat along with their snack!
This would create a new business
opportunity!8
Inventive Problem Solving:
This kind of thinking is in the realm of
innovative problem solving. Generich
Altshuller and others have developed the
“Theory of Inventive Problem Solving” or
TRIZ9, which has become popular in the
recent years. Genrich Altshuller, who
Figure-3 Causal Chain
Machine Defective Rejection
malfunction production by
Customer
Supplier
According to the Theory of Constraints
(TOC) propounded by Dr. E. M. Goldratt
(1984)11, there are a small number of
constraints in a system and there is at least
one constraint that limits the system in
achieving more of its goals. Thus a problem
can be seen to have one systemic constraint
at its root cause.
worked in the patent office of USSR’s navy
in 1940s, analysed 40,000 patent
applications and identified common patterns
in the thinking of inventors, who tried to
solve various technical problems. Based on
it, he developed the 40 Principles of
Inventive Problem Solving.
As the dictum goes, a problem has an
innovation opportunity hiding behind it,
innovative thinking is most important when
dealing with problems. In today’s fast
globalizing economy, competency to
innovate is considered as the key to
sustainable competitiveness of not only
companies but also nations and economic
blocks! 10. Therefore, innovation potential
of the problems needs to be exploited as
much as possible.
Apart from the causes, a problem has other
aspects. The most important aspect is its
consequences. In fact a problem is a part of
a chain of causes, problem and
consequences. (See Figure-3). In risk based
methodologies such as FMEA,
consequences of a problem and probabilities
of occurrence and detection of its causes are
rated to determine RPNs (Risk Priority
Number), which represents the risks
associated with the process.
Customer’s Delivery
production delay by
stoppage customer
Customer
Dragon Diagram
So far there is no one single tool which
pulls together and represents all of the
above described aspects of a problem (viz.
consequence, causes, hidden opportunities
and systemic constraint) for a holistic
understanding of a problem. The tool
proposed here, the Dragon Diagram (See
Figure-4) meets this need (and more) of
Figure 4 – Dragon Diagram
Princess
(Innovation opportunity)
Wicked Villain
(Systemic Constraint)
The tale of a virtuous knight in shining
armour slaying a dragon to save a beautiful
princess imprisoned by a wicked villain in a
castle is very well known. It is a vivid
metaphor in which the dragon that has many
legs with sharp claws breathes fire and the
brave hero fights the dragon dodging the
fire and chopping the dragon off into pieces
eventually freeing the princess.
This metaphor can be used to represent all
aspects of a problem situation. The head of
the dragon represents the problem, the fire
represents consequences of the problem,
legs represent the main factors and fingers
problem solving teams.
Problem
Consequences
of problem
Main cause
Sub-causes
Heroes
(Problem-
solving
Team)
in the claws represent sub-factors. The
imprisoned princess behind the dragon
represents the hidden opportunities for
innovation, learning and replication (i.e. the
opportunity to “dissolve” the problem and
create a superior system).
The wicked villain in this metaphor
represents the systemic constraint, i.e.
cultural and political roots of the problem,
which restrict the development and growth
of the organization, for example
interpersonal or intergroup rivalries, out of
date belief systems, wrong performance
measures and incentives, corruption, etc.
Many a times, technical problems in the
processes have their roots in organizational
policies and politics. (For example, in one
organization the real root cause of high
defect rate was the perceived unfair
treatment of the maintenance department
vis-à-vis the production department).
The members of the problem solving team
are the heroes who slay the dragon by
stopping its fire, cutting off its legs and
freeing up the princess. The team is also
asked to find a way of directly jumping over
the dragon and freeing the princess, which
is the innovative way of dissolving a
problem rather than solving it by
eliminating its root cause(s).
The Dragon Diagram thus offers a number
of advantages compared to the tools such as
Fishbone Diagram, 5 Why analysis and
Mind Map:
a. The metaphor evokes the
emotions of challenge, valour and
fun and thus engages the team
members more enthusiastically.
b. It is very entertaining and
people like it. They become
instantly interested in the process
of problem solving.
c. Because it provides more
holistic description of all aspects
of a problem, the team members’
understanding of the problem,
process and system is more
comprehensive.
d. It becomes easy for the team to
understand the risk based
approach such as FMEA, in which
severity of consequences and
probability of causes have to be
rated.
e. Most importantly, this metaphor
brings people’s attention on the
hidden innovation opportunity, i.e.
the Princess.
f. The metaphor also draws
attention to the real big hairy ugly
issues in the organization, of
which the problem-in-focus really
is one of the symptoms. Such
issues usually don’t appear on the
Fishbone diagram.
Thus by making the problem solving a
heroic story of victory of good over evil, the
whole team gets charged up and enjoys
every bit of it. Story telling is a part of all
cultural traditions and especially the stories
with the theme of victory of good over evil
is liked by people of all cultural
backgrounds.
There is also ample scope for the team to
bring in additional features to stimulate
creative thinking, such as:
 A magical spell cast by the wicked
villain (e.g. disappearance and re-
appearance of the problem),
 Multiple headed dragon (e.g. similar
and closely related problems arising out
of the same process, e.g. inaccurate
invoices and delays in invoicing),
 A wizard who can give some secret
tips to help the team.
 The process flow block diagram can
be considered as the body of the dragon
with legs sprouting from each of the
blocks. Thus causes arising from each
process stage could be identified.
 The metaphor need not be
stereotypically gender biased, i.e.
heroes saving a princess. A team may
change it to a prince transformed into a
frog and imprisoned by a wicked witch!
An Example of Application of the Dragon
Diagram
The author has utilized this tool as a
facilitator to a problem solving team in
Kanoo Travel - a large travel agency in the
Middle East, which provides travel
management services to multi-national
corporations. The team had undertaken to
solve “Delay in processing refund” as a
problem. The cross functional team
consisted of people from different branches
located in various parts of the city. The
team members usually complained of time
spent in traffic to attend the team meetings.
Therefore their participation in the problem
solving process was not quite enthusiastic.
When the dragon diagram was introduced to
the team by the author as the team’s
facilitator, there was a marked improvement
in the level of interest and enthusiasm of the
team members. The discussions became
more animated and creative and the team
members did not want to miss any meeting.
Using the metaphor of the fire breathed by
the dragon the team made a Dragon
Diagram (Figure-5) and identified the
consequences of the problem, such as
customers not paying invoices until the
refunds were processed thus lengthening the
cash to cash cycle and increasing the credit
risk in the market.
The best part was that the team identified
the “Princess” and using the Principle
number 13 (the other way around) of the 40
Innovative Principles of TRIZ came up with
an idea to proactively approach the
customers and seek their approval to
process refund of unutilized tickets rather
than waiting for the customers to request
refund to trigger the process. This proactive
approach, everyone agreed, would enhance
the customer loyalty as it would be
perceived by the customers as additional
care provided by the travel agency. It would
safeguard customers’ interest by avoiding
the risk of expiry of refund deadline in case
a customer forgets to apply for refund. It
would also improve the travel agency’s
income from refund transaction processing
fees and create a competitive advantage.
Figure 5 – Delay in Processing Refund – Actual Dragon Diagram
(Courtesy Kanoo Travel L.L.C.)
The team identified the interdepartmental
blame game (i.e. Operations vs. Accounts)
as the wicked villain in this case in a jovial
manner without offending anyone.
Once the problem was clearly and
comprehensively understood, the team
could work effectively identifying the
process improvement measures as well as
found ways to implement the proactive
approach. The blame game was also
“dissolved” by using this technique.
In another service sector organization, the
tool was tried in a Quality Improvement
training program with a group of
employees. The program was facilitated by
a friend of the author. First the group was
explained Fishbone diagram and was given
an actual problem relating to cycle time
reduction of a certain process. The
facilitator observed the group interaction.
Later he introduced the Dragon Diagram
and asked the team to work again on the
problem. He observed a marked
improvement in the team’s enthusiasm and
interest. The group reported better
understanding of the problem, the process
and the entire system.
Conclusion:
Overall, in both trials, the team based
problem solving process were more
effective compared to using the traditional
Fishbone diagram which many people find
too mechanistic, hair splitting, and hence
boring.
The Dragon Diagram tool especially could
be useful to non-technical organizations
which may not be well tuned to the left
brained logical, reductionist thinking. It
creates a strong emotion of empowerment
and excitement and reduces the intellectual
fatigue, which is reached in brainstorming
sessions. This tool combines powerful core
ideas from a number of streams of thought
such as FMEA, TOC, TSI and TRIZ and
presents a simple to use and inspiring
technique12.
It combines the left brain analysis of Cause
& Effect Diagram with the right brain big
picture and thinking out of the box using the
right brain. Experts agree that the
combination of left and right brain
approaches is far more effective in creative
problem solving.13
Further work:
Though the initial trials have no doubt
demonstrated greater engagement of the
teams and better understanding of the
problem, the proposed tool needs to be tried
out on a wider scale for a variety of
problems, especially in conjunction with the
innovative problem solving approaches,
such as TRIZ. This tool can help enhance
effectiveness of team based problem solving
and improvement.
References:
1
Dr. Kaoru Ishikawa (1989), Introduction
to Quality Control, Productivity Press,
pp 229-233
2
It is called the “3G” Principle by the
Japanese: Gemba, Genchi, Gembutsu or
Go to the actual place, See the actual
thing and Make decisions based on facts.
3
Russell Ackoff (1981), Creating the
Corporate Future, John Wiley, pp 8-9
4
Buzan, Tony. (2000) The Mind Map
Book, Penguin Books, 1996. ISBN 978-
0452273221
5
R.L. Flood and Michael Jackson (1991),
“Creative Problem Solving – Total
Systems Intervention”, John Wiley, pp 7-
15
6
Peter Checkland (1981) referred at
http://systems.open.ac.uk/materials/t552/
pages/rich/richAppendix.html
7
Russel Ackoff (1981) “Creating the
Corporate Future – Plan or Be Planned
for”, John Wiley, pp. 170-171
8
Narayana Peesapaty, Inventor of edible
cutlery, Refer http://www.bakeys.com
9
Generich Altshuller and others (1945-
1985), Refer Altshuller Institute for
TRIZ Studies, http://www.aitriz.org
10
European Commission declared 2009 as
European Year of Creativity and
Innovation. Ref.
http://www.create2009.europa.eu
11
Dr. Eliyahu M. Goldratt (2001), Theory
of Constraints and Its Thinking Process,
(http://www.goldratt.com/toctpwhitepape
r.pdf)
12
It should however be noted here that this
tool is meant only to see the problems in
the light of the various concepts and is
not intended to replace the details
application of various methodologies
referred here, which will result in
benefits of their own.
13
Nelson, Eileen S. (1988), Combating
Counselor Burn-out: The Use of Right
and Left Brain Applications, Paper
presented at the Annual Convention of
the American Association for Counseling
and Development (Chicago, IL, USA,
March 20-23, 1988).