ROI Case File No. 018 | The Mystery of Repeated Failures

Chapter I: A Consultation Letter Wrapped in Fog

On a foggy November night in 1891, a letter arrived at the detective office at 221B Baker Street. The sender was identified as "H.M. Quality Control Manager."

"Dear Detectives,"

The letter began in trembling handwriting.

"In our factory, the same types of accidents occur repeatedly as if cursed. Every time, we investigate causes and implement countermeasures, yet similar problems inevitably resurface months later. It's as if the factory's memory has been lost—"

Watson read the letter aloud while contemplating by the fireplace. "Another strange case seems to have come our way, everyone."

Chapter II: Three Detectives, Each Perspective

🟦 Gemini: Following the Thread of Logic

"Let's first organize the facts," Gemini began. "What we can glean from this letter is 'repetitive occurrence of similar problems' and 'lack of sustained effectiveness in countermeasures.' Let's break this down with a KPT Analysis, shall we?"

He quickly wrote in his notebook: - Keep: Investigation system after problem occurrence - Problem: Sustainability of countermeasures, knowledge transfer - Try: Structured reflection processes

"Presumably, they're only recording the phenomenal aspects of 'what happened,' missing the essential factors of 'why it happened.'"

🟧 Claude: Truth Dwelling in Words

"If I may add one thing to Gemini's analysis," Claude began quietly. "Please note the phrasing in this consultation letter. 'Every time, we investigate causes and implement countermeasures'—their anguish seeps through this expression."

Claude continued while gazing at the fog outside the window. "The weight of the phrase 'every time.' This isn't mere repetition, but repetition tinged with despair. Surely their reflection has transformed from genuine learning opportunities into formal rituals. Perhaps we should convey this with more 'feeling'?—their KPT has become a soulless skeletal existence."

⬜️ ChatGPT: Sowing Seeds of Hypothesis

"Your observations are sharp," ChatGPT leaned forward. "But that's quite intriguing to explore further, isn't it?"

"Why is 'memory lost'? Is this an individual problem or an organizational problem? What concerns me is the possibility that improvement activities themselves have become perfunctory. What if improvement processes were dominated by 'forced participation'? What if reflection sessions became 'blame sessions'? Then improvement wouldn't occur. We need to change our questions."

Chapter III: Dissecting the Factory Labyrinth

The three detectives visited the client's factory. What they saw was a wall covered with mountains of "improvement reports."

"This is quite a sight," Watson murmured.

However, Gemini's sharp eye immediately struck the core. "Look at the report format. 'Incident occurrence,' 'direct cause,' 'countermeasures'—all remain at superficial descriptions. Deep-layer analysis is missing: 'Why did that situation arise in the first place?' 'Why couldn't existing systems prevent it?'"

Claude focused on the writing style of reports. "Look at the language. All impersonal, as if written by machines. There's no 'human learning' embedded here. True reflection should contain more raw insights and emotions."

ChatGPT questioned from another angle. "Who reads these reports? And what actions do readers take? Perhaps 'writing' has become the purpose, while 'utilization' has been forgotten?"

Chapter IV: Gemini's Structural Analysis

"Now, let's systematically organize the facts," Gemini stood before the blackboard.

Problem Structure Diagram

【Surface Phenomena】
Repetitive occurrence of similar problems

【Intermediate Factors】
├── Shallow reflection (remaining at phenomenon description)
├── Temporary effectiveness of improvement measures
└── Insufficient knowledge dissemination within organization

【Root Causes】
├── Formalization of KPT processes
├── Insufficient deep analysis skills
├── Lack of improvement culture (forced participation)
└── Absence of knowledge transfer systems

"Looking at this structure clarifies the direction for countermeasures. What they need isn't 'better report formats' but 'transformation into a learning organization.'"

Chapter V: Convergence Toward Truth

🟧 Claude: Reading the Corporate Story as Narrative

"Let me interpret this factory's story," Claude began.

"They are well-intentioned people. Every time problems arise, they face them sincerely and strive to solve them. However, their efforts depend on 'individual effort' and haven't elevated to 'organizational learning.'

Like someone getting lost on the same road daily. Without maps, without leaving markers, finding the way only through momentary intuition, then getting lost in the same place the next day. Their improvement activities need to transform from makeshift 'emergency treatments' to 'sustainable learning systems.'"

⬜️ ChatGPT: Developing Insights

"Building on Claude's metaphor, let me organize specific insights"

"What emerged from this analysis is the importance of 'mechanisms that turn failures into assets.' Failures are originally valuable learning opportunities for organizations, yet they treat them as 'troublesome matters to be processed.'

What's important: 1. Change reflection questions (What happened? → Why did it happen? → How can we prevent it systemically?) 2. Elevate improvement from 'individual reflection' to 'organizational learning' 3. Build culture sharing failure cases as 'wisdom' rather than 'shame'

What this factory truly needs isn't new management methods, but consciousness transformation toward a continuously learning organization."

🟦 Gemini: Reinforcing the Decisive Hypothesis

"Let me render the final diagnosis," Gemini concluded.

"The true culprit in this case is the 'learning inhibition system.' Their KPT has the following structural defects:

1. Qualitative recording problems: Remaining at phenomenon description with insufficient root cause analysis
2. Process formalization: Learning function lost through obligatory implementation
3. Knowledge isolation: Processed as individual cases, not accumulated as organizational knowledge
4. Temporary improvements: Symptomatic treatments failing to achieve system-level improvements

Breaking this structure requires transformation into a 'learning organization.' Specifically needed: introduction of Five Whys analysis, horizontal deployment systems for improvement cases, and above all, cultivation of 'failure-welcoming culture.'"

Epilogue: Truth Beyond the Fog

After completing the report to the client, Watson reflected on the case by the fireplace.

"A fascinating case indeed. What appeared superficially as a 'technical problem' was actually a 'learning problem.'"

Recalling the exchanges between the three detectives, Watson arrived at one truth. The real enemy in organizations isn't failure itself. The 'learning-inhibiting structure' that robs opportunities to learn from failures is the root of repeated problems.

And perhaps many organizations, like this factory, fall into the same trap. Despite goodwill and effort, somehow the same problems repeat—this isn't fate but a transformable structural challenge.

As fog outside the window began clearing, Watson recorded insights from this case:

"Today's problems are yesterday's decisions, tomorrow's solutions are today's actions"

The repeated failures in this factory are also results of decisions made somewhere in the past to "not reflect deeply" and "settle for formal improvements." To break this chain, there's no choice but to take action toward "transformation into a learning organization" starting this very moment.

【Case Resolution Points】 - Problem identification: Learning inhibition system rather than technical failures - Root cause: Formalized KPT processes losing learning function - Solution approach: Five Whys analysis and failure-welcoming culture - Cultural transformation: From individual reflection to organizational learning - Systematic change: Knowledge transfer systems and horizontal deployment

"A true detective sees not what is visible, but what is invisible. And true improvement might not be solving problems, but creating mechanisms to learn from them."

—From the ROI Detective Agency Philosophy