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is far easier to exclude members of the team from a particular response that it is tolocate, educate and charge a person who has no idea what it means to be a teammember and how to investigate an incident after the event has occurred and timepressures are in full effect.A corollary of the above is that the team is only as good as its leader. A strong,organized and experienced individual should be identified to act as the team leader forthe investigation. The leader may not be the most knowledgeable person on all aspectsor products of the company, but that is not as important as whether the leader willcommit to learn as much as he/she can about those issues AND include and workclosely with others on the team who can fill the gaps in this respect. In the same vein,the fact that a person is the top expert on a particular product or process does NOTautomatically mean that they are effective investigative team leaders. Often, peoplewho have spent a career designing, manufacturing, installing, using or trouble-shootingitems are quick to reach conclusions on what may have occurred, resulting in lessthorough documentation of all aspects of the event. This is counter-productive. Theinvestigation team needs to be methodical, patient and thorough, avoiding thetemptation to jump to conclusions before documenting evidence that would allow theconclusions to be validly drawn based on all factors in play. In fact, the tendency toshort-circuit an investigation goes against the grain of a root cause analysis in that thisanalysis seeks to go beyond the obvious and consider much deeper factors(environment, process, external, etc). The team leader needs to recognize and committo a thorough investigation process – and to garner the respect of the knowledgeablepersonnel he or she must lead.7