Root Cause Analysis, 5th Edition

8

Ordering the Analysis Team

When a sporadic event typically occurs in an organization, an immediate effort is organized to form a task team to investigate “WHY” such an undesirable event occurred. What is the typical makeup of such a task team? We see the natural tendency of management to assign the “cream-of-the-crop” experts to both lead and participate on such a team. While well intended, there are some potential disadvantages to this thought process.

Let’s paint a scenario in a manufacturing setting (even though it could happen anywhere). A sulfur burner boiler fails due to tube ruptures. The event considerably impacts production capabilities when it occurs. Maintenance histories confirm that such an occurrence is chronic as it has happened ...