Root Cause Analysis, 4th Edition

56 Root Cause Analysis: Improving Performance for Bottom-Line Results

thought on the analyst’s part. When we teach this method to our students, their usual

response is to take an entire facility and make it the system. This is a prescription

for disaster. Trying to delineate all of the failures and/or problems in a huge oil

renery, for instance, would be a daunting task. What we need to do is localize the

system down to one system within a larger system. For instance, a large oil renery is

comprised of many operating units. There is a Crude Unit, Fluid Catalytic Cracking

Unit (FCCU), Delayed Coking Unit (DCU), and many others. The prudent thing to

do would be to select one unit at a time and make that unit the focus of the ana