When something goes wrong, especially in a large organization, there can be an instinct to point fingers and shift blame. This probably isn’t the best way to prevent the problem from arising in the future though. Sakichi Toyoda, the founder of Toyota Motor Company, developed the “5 Whys” process, a type of root cause analysis, to identify and fix problems that arose within the company. It has since been widely adopted as part of lean manufacturing, Kaizen, and Six Sigma methodology.
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.