Incident investigation workshop


TIPS FOR BUILDING GOOD WHY TREES



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How to develop a Why Tree-2012 DHK

TIPS FOR BUILDING GOOD WHY TREES

  • TIPS FOR BUILDING GOOD WHY TREES
  • IS THE CAUSE and EFFECT TRUE?

TIPS FOR BUILDING GOOD WHY TREES

  • TIPS FOR BUILDING GOOD WHY TREES
  • Intangible Cause
  • Tangible Effect

TIPS FOR BUILDING GOOD WHY TREES

  • TIPS FOR BUILDING GOOD WHY TREES
  • Experience shows you should drive at least five (5) levels (5 times) to get to operating system key factor (S)
  • WHY
  • WHY
  • WHY
  • WHY
  • WHY
  • FAILURE EVENT
  • KEY FACTORS
  • Physical Causes
  • Human Causes
  • System Causes
  • HOW MANY TIMES DO YOU ASK WHY?

WHEN BUILDING A WHY TREE

  • WHEN BUILDING A WHY TREE
  • When You find the Root Key Factor(s) at the
  • Operating System,
  • OR
  • At the point where you no longer have control or
  • influence over the solution.
  • There are certain things you have neither control nor influence over. Forget about them, or get the appropriate person(s) to deal with them.
  • An example is the 35A and the 50A fuses in the WHY Tree example, which are manufactured nearly alike.

HOW LONG DOES IT TAKE TO COMPLETE A WHY TREE

  • HOW LONG DOES IT TAKE TO COMPLETE A WHY TREE
  • Depends on the complexity of incident and number of observations or "branches" to be processed.
  • Consider breaking "WHY Tree" sessions down into segments to maintain group focus and energy.
  • Two hour segments recommended.
  • Verification activities should occur between sessions with report back.
  • Don't rush the process - sacrifice quality of investigation and ultimately the findings / improvements.

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