Når noe går galt, spesielt i en stor organisasjon, kan det være et instinkt å peke på fingrene og skifte skyld. Dette er sannsynligvis ikke den beste måten å forhindre at problemet oppstår i fremtiden skjønt. Sakichi Toyoda, grunnleggeren av Toyota Motor Company, utviklet "5 Whys" -prosessen, en type grunnårsaksanalyse, for å identifisere og løse problemer som oppsto i selskapet. Det har siden blitt mye vedtatt som en del av lean manufacturing, Kaizen og Six Sigma metodikk.
The kingdom was lost. Specifically: the castle and countryside were set on fire by a dragon.
Lysbilde: 2
1st Why
There was no way to stop the dragon setting things on fire.
Lysbilde: 3
2nd Why
The dragon defeated the unmounted knight in battle.
Lysbilde: 4
3rd Why
The knight's horse refused to be ridden.
Lysbilde: 5
4th Why
The horse had lost a shoe.
Lysbilde: 6
5th Why
The blacksmith did not use the correct number of nails in shoeing the horse.
Lysbilde: 7
The Root Cause
For want of a nail, the kingdom was lost.
Lysbilde: 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.