The Problem
1st Why
2nd Why
3rd Why
4th Why
5th Why
The Root Cause
Countermeasures
The kingdom was lost. Specifically: the castle and countryside were set on fire by a dragon.
There was no way to stop the dragon setting things on fire.
The dragon defeated the unmounted knight in battle.
The knight's horse refused to be ridden.
The horse had lost a shoe.
The blacksmith did not use the correct number of nails in shoeing the horse.
For want of a nail, the kingdom was lost.
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.
Royal Horseshoe Inspection Checklist
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