Incident investigation workshop
WHAT HINDERS THE WHY TREE PROCESS?
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How to develop a Why Tree-2012 DHK
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TOOLS FOR DRAFTING WHY TREE
WHAT HINDERS THE WHY TREE PROCESS?
WHAT HINDERS THE WHY TREE PROCESS?
Not verifying the
Hypotheses thoroughly enough
Misidentify symptoms for root cause
Not focusing
on the management systems
Not brainstorming enough at each intermediate causes
Stopping too soon before all
Key Factors are determined
"Failure to follow procedures" or "Operator Error" trap
Having a dictatorial WHY TREE leader/manger
WHY TREE leader has a personal stake in the outcome
Not having the right
people in the WHY TREE team
Chart
3-41
TOOLS
FOR DRAFTING WHY TREE
TOOLS FOR DRAFTING WHY TREE
Chart Pads
Post It
PowerPoint
Excel
DISCUSSION ON COMPLETED Y TREES
3/31/2011
EXERCISE
Make a Y-tree
of the incident of SO Sukkur
3/31/2011
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