Quando algo dá errado, especialmente em uma grande organização, pode haver um instinto para apontar os dedos e mudar a culpa. Isso provavelmente não é a melhor maneira de evitar que o problema surja no futuro. Sakichi Toyoda, o fundador da Toyota Motor Company, desenvolveu o processo "5 Whys", um tipo de análise de causa raiz, para identificar e corrigir problemas que surgiram dentro da empresa. Desde então tem sido amplamente adotado como parte da fabricação enxuta, Kaizen e metodologia 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.