Root Cause Analysis, 4th Edition

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

of our organizational systems are put in place to recognize these changes.

For example, the predictive maintenance group’s sole purpose is to utilize

testing equipment to identify changes within the process and equipment. If

changes are not within acceptable limits, actions are taken to make them

within acceptable limits.

2. By witch-hunting the last person associated with an event, we give up the

right to the information that person possesses on the other errors that led

up to the event. If we discipline a person associated with the event because

our culture requires a ...