Kada nešto pođe po zlu, pogotovo u velikoj organizaciji, može biti instinkt za usmjeravanje prstiju i pomicanje krivnje. To vjerojatno nije najbolji način za sprečavanje nastanka problema u budućnosti. Sakichi Toyoda, osnivač Toyota Motor Company, razvio je proces "5 Whys", koji je vrsta analize korijena, identificirati i popraviti probleme koji su se pojavili unutar tvrtke. Od tada je široko usvojen kao dio proizvodnje mršave proizvodnje, Kaizen i Six Sigma metodologije.
The kingdom was lost. Specifically: the castle and countryside were set on fire by a dragon.
Slajd: 2
1st Why
There was no way to stop the dragon setting things on fire.
Slajd: 3
2nd Why
The dragon defeated the unmounted knight in battle.
Slajd: 4
3rd Why
The knight's horse refused to be ridden.
Slajd: 5
4th Why
The horse had lost a shoe.
Slajd: 6
5th Why
The blacksmith did not use the correct number of nails in shoeing the horse.
Slajd: 7
The Root Cause
For want of a nail, the kingdom was lost.
Slajd: 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.