A root cause analysis (RCA) investigation is rarely a one-person effort. To identify the causes of an incident and develop effective solutions, RCA facilitators are charged with leading the investigation into why the incident happened. They do this by talking to different people and bringing their collective knowledge together for productive conversations.
Given the collaborative nature of RCA, people often ask me: Do I need to start by building an investigation team? And if so, who should be on it?
I’ll answer the first question right off the bat: No, you do not need to build a team before starting your analysis. Almost always, you’ll have some information—whether it’s a couple of sentences, a few pictures, or a casual hallway conversation—that allows you to begin the analysis. We always encourage facilitators to start with what they know to build out the Cause Map™ diagram the best they can.
Drafting the initial Cause Map diagram often provides a launching point to identify who to add to the investigation team. As an investigation progresses, it usually becomes clear who needs to be involved on the investigation team.1 When you’re faced with a question you can’t answer, you’ll need to pull in someone who can. When you reach the limits of that person’s knowledge, you’ll need to involve another person. Eventually, you’ll pull together a team of people who’ve contributed to the investigation—but there’s no need to do it right at the start.
Because the formation of the investigation team stems from the progress of the investigation, there’s no one right answer as far as what the team should look like. But for those who are new to RCA facilitation, I’ll share what I typically see as far as the composition and size of successful teams.
In terms of size, what works best for an investigation team is the same as any other project team. Smaller teams, around four to seven people, make scheduling and communication a lot easier. That said, larger incidents tend to involve more process breakdowns across different parts of the company—and that often means you’ll need to pull in more people.
An effective investigation team includes a diverse representation of roles including:
As a facilitator, your role is not to manage the team but to guide the investigation process. Think of yourself as a steward rather than a traditional “team leader.” Your goal is to make things easier for the team, keeping the investigation on track and ensuring that all perspectives are considered. This often means using one-on-one or small group meetings, which can encourage more open communication than larger group settings. People may feel more comfortable sharing insights privately that they wouldn’t express in a big meeting, and small meetings help avoid the fatigue of lengthy sessions week after week.
If you have a week where you have a lot of one-on-one conversations, it may be helpful to pull everyone you talk to together to make sure you’re not drifting from the collective knowledge of the incident. The completed Cause Map diagram becomes the collective knowledge of why the incident occurred, so we want to make sure that all contributors are included and on the same page.
Facilitators should also be aware of the need to navigate organizational politics. Unfortunately, politics can sometimes influence who’s on the team more than the actual needs of the investigation. Regularly assess whether the right people are involved in each discussion and adjust accordingly. You don’t need to (and, let’s be honest, you may not be able to) kick people out of the team, but you can exclude certain individuals from certain meetings to ensure productive conversations.
In my experience, it’s wise to take a flexible approach with investigation teams. Don’t rush to define who’s in and who’s out at the start. As the investigation progresses, you might need to involve people you hadn’t initially considered, while other stakeholders may only need to contribute at specific stages. Flexibility in team composition allows you to move the investigation forward more efficiently, ensuring thoroughness without dragging out the process with unnecessary meetings. This approach keeps your investigation focused, effective, and more manageable for everyone involved.
1 - Note that an investigation team is distinct from an RCA program team. Investigation teams are formed as needed to support specific investigations. Some organizations may also have an RCA program team to provide ongoing oversight and accountability for RCA.