Ko gre kaj narobe, še posebej v veliki organizaciji, ne more biti instinkt, da kaže s prsti in premik krivde. To verjetno ni najboljši način za preprečevanje težav, ki nastane v prihodnosti, čeprav. Sakichi Toyoda, ustanovitelj družbe Toyota Motor Company, razvil "5 Whys" proces, ki je vrsta analize temeljnih vzrokov, za prepoznavanje in odpravljanje težav, ki so nastale v družbi. Ugotovljeno je bilo, ker na široko sprejeta kot del vitke proizvodnje, Kaizen in metodologijo Six Sigma.
The kingdom was lost. Specifically: the castle and countryside were set on fire by a dragon.
Zdrs: 2
1st Why
There was no way to stop the dragon setting things on fire.
Zdrs: 3
2nd Why
The dragon defeated the unmounted knight in battle.
Zdrs: 4
3rd Why
The knight's horse refused to be ridden.
Zdrs: 5
4th Why
The horse had lost a shoe.
Zdrs: 6
5th Why
The blacksmith did not use the correct number of nails in shoeing the horse.
Zdrs: 7
The Root Cause
For want of a nail, the kingdom was lost.
Zdrs: 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.