Når noget går galt, især i en stor organisation, kan der være et instinkt til at pege fingre og skifte skyld. Dette er nok ikke den bedste måde at forhindre, at problemet opstår i fremtiden. Sakichi Toyoda, grundlæggeren af Toyota Motor Company, udviklede "5 Whys" -processen, en form for grundårsagsanalyse, til at identificere og løse problemer, der opstod i virksomheden. Det er siden blevet bredt vedtaget som en del af Lean Manufacturing, Kaizen og Six Sigma-metoden.
The kingdom was lost. Specifically: the castle and countryside were set on fire by a dragon.
Glide: 2
1st Why
There was no way to stop the dragon setting things on fire.
Glide: 3
2nd Why
The dragon defeated the unmounted knight in battle.
Glide: 4
3rd Why
The knight's horse refused to be ridden.
Glide: 5
4th Why
The horse had lost a shoe.
Glide: 6
5th Why
The blacksmith did not use the correct number of nails in shoeing the horse.
Glide: 7
The Root Cause
For want of a nail, the kingdom was lost.
Glide: 8
Countermeasures
Royal Horseshoe Inspection Checklist
The Royal Horseshoe Inspection Department will make a checklist for all blacksmiths in the kingdom to follow when shoeing a horse, so that no nails are forgotten in the future.