Kad kaut kas noiet greizi, jo īpaši lielā organizācijā, var būt par instinkts norādīt pirkstus un novirzīt vainot. Tas, iespējams, nav labākais veids, kā novērst šo problēmu rašanos nākotnē, lai gan. Sakichi Toyoda, dibinātājs Toyota Motor Company, izstrādāja "5 Kāpēc" procesu, veidu cēloņu analīzi, lai identificētu un novērstu problēmas, kas radušās uzņēmuma ietvaros. Kopš tā laika ir plaši pieņemts kā daļa no liesas ražošanā, Kaizen un Six Sigma metodoloģiju.
The kingdom was lost. Specifically: the castle and countryside were set on fire by a dragon.
4th Why
There was no way to stop the dragon setting things on fire.
5th Why
The dragon defeated the unmounted knight in battle.
The Root Cause
The knight's horse refused to be ridden.
Countermeasures
The horse had lost a shoe.
The blacksmith did not use the correct number of nails in shoeing the horse.
For want of a nail, the kingdom was lost.
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.
