A3 Reports
The named instruments for learning from what happened: one page per problem, the five whys, stop–keep–start, lessons written where the next work will meet them.
An A3 is a whole problem on a single page — background, current condition, the goal, the analysis, the countermeasure, the check. Its discipline is the size of the paper: a problem that cannot be stated on one page has not yet been understood. Beside it sit the other instruments. The five whys, asking why down through the symptoms until a cause is reached that can actually be acted on. Root cause analysis, its wider name. Stop, keep, start, the three columns a body fills together at a turning. Lessons learned, which only count once they are embedded.
They are load-bearing because a gap that is felt and not examined teaches nothing. The gap supplies the material; these supply the method; Every Defect Is A Gift supplies the posture that makes it safe to bring one. Cause is sought in the set-up before the person — a missed commitment traced honestly usually lands on a constraint that was never logged, and blaming the committor would have hidden it.
They are held lightly. Asking why five times by rote stops at symptoms; investigators find only causes they can already imagine; and insisting on a single root cause can be wrong where several are real. These are means, not ends — instruments that challenge a body to look deeper, and that fail whenever they become a form to fill in.
Also called: Lessons Learned · Stop-Keep-Start · The 5 Whys · Root Cause Analysis Stands on: The gap · Zero Blame Environment · Tightly Coupled Learning and Action Opens onto: Every Defect Is A Gift · Retrospective · Continuous Improvement · Quality In play: table · Home Sources: Root Cause Analysis And The 5 Whys (wiki root page, unmarked; carries its own critique of rote use) · The LIØNSBERG Pattern Language — Synthesized (Element 12, where A3 Reports, Lessons Learned and Stop-Keep-Start are named) · The LIØNSBERG Operating System (book, draft v0) §13 — lionsberg.wiki page name: Root Cause Analysis And The 5 Whys Open: A3 Reports itself is a named instrument with no page of its own; only the five whys is written out.