September 21, 2011 | Barb Carr

Root Cause Analysis Tip: Investigation Team Facilitation

You get the call that there has been an incident that needs to be investigated. So, you begin mapping out the SnapCharT®, performing the root cause analysis or developing the corrective actions and this happens (Watch Video):

(Link to video if unable to click on the video:

Never fails, too many Type “A” personalities in the room, and you are the one who has to facilitate the team. It does not matter whether you have a Type “A” or “B” personality, it can get ugly if it is not handled correctly, especially if someone was hurt (or worse) or if the company lost a lot of money. So what to do …

Here are a few facilitation hints:

1. Define who the team lead is upfront. (This prevents an Accountability NI issue.)

Note that the investigation facilitator does not have to be the one who is in charge. After all, the facilitator’s true role is to facilitate the TapRooT® 7 Step Root Cause Analysis Process, not necessarily the team members themselves. It can also help if the facilitator is a neutral person not familiar with the incident or process being investigated.

2. Allow all members to introduce themselves … often new people are introduced into an established team. The introduction gives a person, new or shy, the platform to speak up later.

3. While developing the SnapCharT®, (or time line for friends new to our process), ensure that all the people, equipment, and process actions that occurred are listed, whether people think they are an issue related to the incident or not. You can make a movie with a good time line of events.

Note that this enables the good actions of all members, divisions, contractors, clients and owners to be listed as well and removes some of the blame and finger pointing that can occur.

4. While using the Root Cause Tree Dictionary, Root Cause Tree and SnapCharT® to find Root Causes for your Causal Factors, it is never an “I am right ” or “You are wrong” discussion. Unknown to untrained TapRooT® team members, the facilitator has carried in the “Arbitrator”!

Great, another “A” type in the group you say? Well, yes and no, the “Arbitrator” is the Root Cause Tree Dictionary.

The Root Cause Tree has lots of experience and knowledge to gently nudge any group into the right choice. It comes with some explicit rules … facts, facts, facts! You select a root cause because it related to or impacted a particular Causal Factor. A Root Cause is not selected because you have already decided on what you want the corrective action to be. It is also not ignored because you think you cannot change it. Root causes are just the facts.

Here is an example of how the Root Cause Tree Dictionary arbitrates and removes the emotion for the Causal Factor of “Operator opened the Fuel Supply Valve with a Contaminated Fuel Supply.” This is just one of the Causal Factors for the Incident of a motor being damaged with lots of downtime costs.

Two team members are in a heated discussion as to whether the Operator could detect or could not detect the contamination while opening the valve …

One team member who believes that the Operator had the knowledge of the contamination in the line is focused on what was seen after the fuel supply system was opened up.

The other team member believes that the Operator could not see inside the system while opening the valve.

You, (as the facilitator), walk up to the arguing pair and without telling either member who may be right or may be wrong, you say, “Open up the Root Cause Tree Dictionary and tell me which fact (condition on the SnapChrarT®) matches the bullet in the Root Cause Tree Dictionary.”  Now state the fact and say, “this relates to why the Operator opened the Fuel Supply Valve with a Contaminated Fuel Supply.”

By focusing on the facts as known by the operator at the time he was opening the valve, the contamination was unknown and not detectable. The contamination was identified after the fact and only after taking apart the manifolds and valve.

The “Arbitrator” saves the day again with emotions and opinions removed!

Try these steps and also let me know in the comment section, what else you have done to reduce bias and emotions during your investigation facilitation.

Want to learn more about leading investigation teams?  Attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Training.

Root Cause Analysis
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