Cuando algo va mal, especialmente en una organización grande, puede haber un instinto para apuntar con los dedos y cambiar la culpa. Esto probablemente no es la mejor manera de evitar que el problema surja en el futuro sin embargo. Sakichi Toyoda, el fundador de Toyota Motor Company, desarrolló el proceso "5 Whys", un tipo de análisis de la causa raíz, para identificar y solucionar problemas que surgieron dentro de la compañía. Desde entonces ha sido ampliamente adoptado como parte de la fabricación lean, Kaizen y la metodología Six Sigma.
The kingdom was lost. Specifically: the castle and countryside were set on fire by a dragon.
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1st Why
There was no way to stop the dragon setting things on fire.
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2nd Why
The dragon defeated the unmounted knight in battle.
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3rd Why
The knight's horse refused to be ridden.
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4th Why
The horse had lost a shoe.
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5th Why
The blacksmith did not use the correct number of nails in shoeing the horse.
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The Root Cause
For want of a nail, the kingdom was lost.
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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.