The president of Siyuan Energy (Siyuan) faced the long-standing problem of a very high rate of top management turnover. By 2019, Siyuan had grown to five hundred employees and ¥170 million in revenue; however, over the past decade, the turnover rate of executives had grown dramatically. Few of the externally hired executives lasted even a year, and now a number of long-time internal executives were also leaving. Morale was declining at the same time that the company was facing growing competition. Action was required to address the problem, but analysis was first needed to understand whether such high turnover was due to systems or leadership, or both.