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An employee in the logistics warehouse slipped on an unmarked wet floor, resulting in a sprained ankle.
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From the blog
A single chain of 'why' explains the trigger and misses the disaster. A 3-legged 5-Whys runs three parallel chains — what failed, what let the warning slide, and what shaped the decision — so the fix lands on the system, not the symptom.
The engineers had the data and the right answer the night before Challenger launched. A single flip in the burden of proof was enough to overrule them. How a go/no-go hold point quietly inverts under pressure — and how to catch it in your own organization.
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