Root Cause Analysis, 4th Edition

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9

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 make-up of such a task team? We see the natural ten-

dency 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 disadvan-

tages 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 pro ...