Friday, March 24, 2017
I have recently wondered if I'm a bit off my rocker.
Either everyone else is missing something HUGE, or I'm the one that's living in an unreal world.
The subject of my wondering is "why do things go wrong." I'm not sure anyone else wonders about this -- seriously wonders.
Why, in our earthly existence, do things go wrong?
I'm increasing convinced that things go wrong TO CHANGE PEOPLE.
I can think of no other reason why our existence should include "things that go wrong" other than to change the way we think about ourselves, our fellow human beings, our surroundings, and our relationship to our Creator.
If this is true, then what we call "problem solving" might have become one of the most dangerous enterprises of humanity.
Think about it. We get an idea. We map out our plan to achieve it. We set the plan in motion. We encounter a problem. We set out to understand the problem and then eliminate it. And on, and on, and on. This is the world we live in.
Almost all of my "root cause analysis" competitors make a living by promising to help organizations "solve their problems." The result is more and more, faster and faster -- the merry-go-round of life, a whirling, dizzying phenomena that we have all been born into.
Isn't there something PROFOUNDLY MISSING in our "problem-solving-focus?" Isn't ANYONE willing to wonder about the deeper truths of our problems?
Where, in our "root cause analysis," or "problem-solving efforts" does anyone wonder "is this a valid idea?" "Is this problem trying to tell us something about ourselves?" "What is it about the way we are that contributed to this problem?" More importantly, "what is it about the way I am is apparent in this dilemma?"
Our present focus on problem-solving is like a glutton who is focused on eating. It'll eventually kill the glutton.
If the glutton would only realize that A MORE LOFTY FOCUS (let's say a focus on health) would certainly bring him food, but in the right dosage and types. It would also include exercise and general moderation.
Shouldn't we have a more lofty goal when things go wrong -- a higher-level goal than MERELY PROBLEM SOLVING?
Shouldn't that more lofty goal be "to CHANGE PEOPLE?"
After all, when people change, everything else changes.
Please let me know why you might disagree, or agree. I'd love to hear your thoughts.
Monday, March 06, 2017
One of the most life-changing experiences I’ve ever had was while working at Morton Thiokol in the winter of 1986. I was working there as a root cause analysis consultant when the Challenger exploded and was there while the incident was being investigated. Because I was there, I suppose, I became more engrossed than most people in the causes of the event.
This one event SINGULARLY ripped me out of my purely engineering shell and THRUST me into the realm of the human behavior.
I don’t have time to share the whole story in this short vlog, but I would like to challenge you with a few questions to help you understand some of the underlying causes of the event. I’ll ask you 7 questions.
As I share theses questions, please ask yourselves what it is that REALLY causes our problems? Is it systems, or is it us?
Here are the 7 questions:
- Have you ever gone forward with any kind of endeavor IN SPITE OF an anomaly popping up that you didn’t quite understand? Ever?
- Have you ever been called “unreasonable” in the past, and were in the midst of trying to correct that impression when another situation occurred where all the players were ready to “go” except yourself? In other words, have you ever tried to be “reasonable” in a risky situation?
- Have you ever gone by the book even when you were suspicious that the book was not good enough in this instance, because if anything does go wrong, you can point back to the book and say “I was only following procedure!” Ever?
- Have you ever done something risky because you did it before and got away with it?
- Have you ever ignored your gut feelings when they told you to be more careful, even though the data said you were okay?
- What do you do when you ask someone for their advice and you don’t like their answer? Do you ever argue with them, or try to change their minds? Why? Why ask in the first place if you’re not willing to hear the answer!
- Now let’s turn it around. What do YOU do when someone asks YOU a question and they don’t like YOUR answer? Do you back down and let them persuade you that they are right? Before you say “no, I’d never do that,” let me ask you this. What if it was your boss, or the client who said something like “either change your answer or we’ll find someone else?”
I wish I could see your faces when you read these – and I also wish you’d dwell on each of these a long, long time – because almost all of us are guilty of almost all of these! These are the kinds of things that caused the Challenger disaster.
So here’s the point. Are any of the things I’ve mentioned SYSTEM-type causes? You know, procedural, or checklist, or work-flow related? That’s what most root cause analysis methods suggest – that our problems are caused by our SYSTEMS. Is that true?
Naaaaaaa……. NASA and their contractors probably had the best systems in the world, and look what happened in spite of their systems.
It’s not our systems that cause problems – it’s US – our attitudes, beliefs, assumptions, and tendencies. Each of us. All of us.
When small things go wrong in your life, ask yourself "what is it about the way I am that contributed to this incident, and what am I going to do about it?" Ask yourself this question over and over, each time something small goes wrong in your life.
You just might avoid the killing or maiming of yourself, your loved ones, your friends, and your neighbors.
Tuesday, February 21, 2017
IntroSpect -- an Important Concept for a People in Crisis
I have been looking at things that go wrong for almost all of my adult life, and I have been drawn deeper and deeper into this fascinating field almost daily.
Looking back, however, I think the most significant thing I've learned as I've confronted the many issues surrounding the "failures" of our lives is the need for:
INTROSPECTION instead of BLAME
As you continue reading, imagine a world where everyone looked at themselves as part of their problems instead of blaming other people and things.
Let's say something goes wrong in your life. It could be anything. You could be involved in trying to launch a space shuttle, and it exploded in mid-air causing 7 people's death. You could be mayor of a city with staggering murder statistics. You could be a hospital administrator who has just been notified of a medication error that resulted in a death.
Or you could be a homeowner whose new drone crashed-landed. That's what happened to me, and I'll use it as an example of what IntroSpect asks people to do.
I received a new drone for Christmas.
A month or so after I got the drone, an incident occurred when I was flying it. One of the propellers suddenly broke apart when it was flying and the drone crash landed.
In trying to understand the causes of my drone failure, the first thing I did was to gather a lot of evidence. I'll not say anything more about the evidence-gathering process -- that's a subject for another blog.
After gathering all the evidence, the next thing I wanted to know was HOW the propeller broke. They key word is HOW – a focus on the PHYSICS, or MECHANICS of the event.
I determined that a shroud that normally protects the one of the propellers had flexed too much while aloft and came in contact with the propeller – shattering the propeller.
Please note that this would be the same step no matter what the incident: a space shuttle explosion, a murder on the streets of a city with staggering murder statistics, a medication error in a hospital that led to a death, or whatever. I've learned the importance of UNDERSTANDING THE PHYSICS (or how) FIRST.
Now here is where it get’s REALLY interesting.
Now that I’ve understood the PHYSICS (or the HOW), I’d now ask:
What did I do that ALLOWED OR ENABLED the Physics?
Another way of asking this question is: who did what wrong that allowed or enabled the physics?
In the case of the drone failure, sure at this point I could stop and simply BLAME the incident on the manufacturer. After all, they DID have a role. But what good does it do ME to merely BLAME the manufacturer? Is that why this incident happened to me -- to teach me to BLAME other entities for my problems? Am I to take no ownership whatsoever for the problems in my life?
In the case of the shuttle explosion, "who did what wrong within the shuttle launch organization?" In the case of the murder in a city with high murder statistics, "who did what wrong within the city (administrators, police, or whoever)?" In the case of the medicinal error in the hospital," who did what wrong" that led to this error?"
Getting back to the drone, what did I do that allowed or enabled the physics?
Well, I'll admit that I flew the drone in wind conditions that were too high! That was my role.
These kinds of "admissions" are always a part of the IntroSpect process. And there is always more than 1 person that needs to make this kind of admission. As I suggested before, if I involved the drone manufacturer in this process, they might have admitted “we manufactured our drones with protective shrouds that are too flimsy.”
But let’s focus on me right now so I can show you the POWER of what’s next. Remember, I flew the drone in wind conditions that were too high!
Now here is where it get’s REALLY, REALLY interesting.
Why did I do what I did? Why does anybody do anything? Isn’t it true that everything we do is caused by the THOUGHTS going through our mind at the time we did it? Think about that, and you’ll see how simple all this really is.
So “what thoughts WERE going through my mind when I decided to fly my drone that windy day?” Well, something like:
I’ve been waiting to fly this drone on the Blue Ridge Parkway to get some spectacular shots ever since I got this drone. THIS IS THE DAY! It’s a bit windy, but this is a good drone. It can handle it.
Think about where this would take YOU if you did this on a problem that occured in your life. Think about the space shuttle example, the murder in the city, the hospital where the medical error occurred -- in ALL these cases there were people who did something because of specific THOUGHTS that went through their minds at a particular point in time.
My next question will take me to another place – it will be a major step towards personal growth, because now I will ask myself:
What thoughts SHOULD have been going through my mind that would have AVOIDED this incident in the first place?
I guarantee that if you ask yourself this question as a result of something that has gone wrong in your life where you, yourself were part of its causes, this question will cause you to STRUGGLE! Things that go wrong in our lives should always cause us to STRUGGLE.
In the case of my drone, I struggled and struggled and finally realized that I SHOULD have thought:
Although I’ve been waiting since Christmas to fly this drone on the Blue Ridge Parkway, it’s a bit too windy to try it today -- and it’s probably even more windy aloft. I think I remember reading that we’re not supposed to fly it in high wind conditions, so I’ll wait for a better day.
Now it's time for me to reflect on 1) what I ACTUALLY thought, versus 2) what I SHOULD have thought.
Actual thoughts versus desired thoughts -- actual thoughts versus desired thoughts. I need to DWELL on this, and then move on to answering…
What is it about the way I am that is evident in these thoughts?
Imagine doing this every time something went wrong in your life! Imagine what would happen if EVERYONE involved asked these kinds of questions, each time something went wrong -- over and over.
Imagine an organization that launches rockets into space doing this, and the city that is experiencing high murder statistics, or the hospital that is plagued with medical errors. Imagine your family doing this.
We are a people in crisis -- a crisis of blame and misunderstanding. No-one is listening to one another. We all have our own agendas.
Things that go wrong are the ONLY phenomena of life that are capable of prying each of us out of our own biases -- as long as we're willing to abide by ONE GOLDEN RULE:
Let's all stop blaming other people and things, and instead started looking at ourselves as part of our problems.
Monday, February 13, 2017
One of the things about HUMAN nature that makes it unique to just about everything else is our tendency to BLAME other things and people when something goes wrong around us.
I don’t think cats “blame.” I don’t think that apes or monkeys blame. I doubt that frogs blame. But ALL HUMAN BEINGS blame. It’s in our nature to do so.
We, as humans, are BLAMERS – all of us. It’s as if we’ve been infected with a BLAME VIRUS.
I'd like to talk about this part of our human nature, and I need to be VERY SPECIFIC in what I say.
First, our human tendency to blame is arguably the WORST part of our nature. NOTHING – absolutely nothing good can come of it. There are some who say that our BLAMING tendency is INCREASING – that it’s gone VIRAL and in epidemic proportions. From my perspective, I agree. Our world is going amok and the blame virus is at the root of most, if not all our problems.
Now let’s bring this back to the services Failsafe provides:
Our approach to learning from things that go WRONG (called Latent Cause Analysis) confronts the blame virus HEAD ON, because with an LCA,
NO BLAME IS ALLOWED.
If I were the CEO of GM, Apple, GE, or whatever and something went wrong in my corporation, all my people would know that the only time they’d have to fear for their job is if they were BLAMING something or someone ELSE for the problem. NO BLAME would be allowed! As a husband and father, I do my best to make sure the same rule applies in my home.
NO BLAME ALLOWED.
This also means NO IMPOSED PUNISHMENT for anything that anyone has done that might have caused a problem, because It is impossible to want to punish someone without blaming them – impossible.
No blame. No punishment when something goes wrong.
Now I know how that sounds. I’ve been around for a while and I’ve seen the eyes roll, and the smirks appear, and the body language that reveals where most people are on this issue. Most of you might think this is nuts. So let me continue.
Let’s talk about rules, policies, procedures and the like – and people who don’t follow them.
Please recognize that the reason we have rules, policies and procedures is to PREVENT things that go wrong. This is true at work, of course, and it’s also true in our communities, and at home. Stop Signs exist to PREVENT traffic accidents, right?
Therefore, the time to discipline people, or even to punish people is BEFORE something goes wrong – not after. Before a traffic accident, not after one!
If someone breaks a rule, (runs a stop sign) ADDRESS IT IMMEDIATELY. Ask “why did you break the rule,” and if there’s not a good answer then PUNISH THE PERSON. If it happens again, PUNISH MORE SEVERELY. If I happens even again, fire the person. If it’s a home problem and it’s a teenager that you’re dealing with, you’ll have to decide on very harsh measures if you are dealing with a child who continually breaks the rules. If it’s running stop signs, take away their license!
The point is to impose the discipline, or punishment, BEFORE something goes wrong, not after. What sense does it make to turn the head the other way UNTIL something goes wrong AND THEN “WACK?” By then, the WACK IS TOO LATE.
So when something does go wrong, I'd suggest that no-one in your company is to blame, punish, discipline, or whatever for anything that goes wrong – for any reason.
Did you hear me say HOWEVER? Most people are so IN SHOCK about what I said about NO BLAME and NO PUNISHMENT after an incident that they don’t ever seem to hear what’s coming. So are you ready????
As I said , NO BLAME as a result of an incident,” but there will be REQUIRED INTROSPECTION.
REQUIRED, as a condition of future employment.
Now, what do I mean by introspection? Well, everyone involved in whatever went wrong – from the hands-on person, to their supervision, to the management of that supervision – all the way up to the CEO if appropriate MUST ANSWER 2 questions:
First, TOGETHER they all answer: what is it about the way WE are (as an organization) that contributed to this incident, and what are WE going to do about it?
Let that sink in. Imagine the power of this question.
Secondly, and most importantly, each person, individually, in front of one another – from the hands-on to the senior levels, is REQUIRED to answer:
What is it about the way I AM that contributed to this incident and what am I going to do about it.
No blame. Required introspection.
We, at Failsafe, think that this elegantly simple, but profound shift in perspective is capable of changing the world around us.
We don’t THINK this will help. We KNOW this will help.
Please think about it.
Please share this BLOG.
Please let us know if we can help.
Tuesday, February 07, 2017
I wish we would have thought of something different to call our approach to learning from things that go wrong, because Latent Cause Analysis sounds like what one might find when looking for "latent organizational weaknesses," and the two would not be more different.
Let me tell you a short story to help you understand its essence.
A family was eating dinner together. It was Friday evening, and it was part of their tradition to eat ice cream for dessert on Friday’s. The father got up to get the ice cream, and discovered there was not enough left for everyone to eat. The mom said “no worries – if you clean the dishes while I’m gone, I’ll go down to the store and get some more ice cream – I’ll be back in 15 minutes.” So she went to the store and bought the ice cream, and then got back into her car for the short drive home.
She approached an intersection and the traffic light turned red. She stopped the car to wait for the green light. But when she rolled to a stop, the car started idling VERY ROUGH. Two seconds later, it stalled.
She thought “OH NO, NOT AGAIN!” She tried to start it, and it wouldn’t start. She kept cranking the engine. It wouldn’t start. She was the first car at the light when the light turned green, but she couldn’t start the car! There were about 15 cars behind her, waiting to get through the light. They all started getting impatient. Some of them started honking their horns. Others passed her, and were not very happy.
Someone finally helped her push the car to the side of the road and then drove her back home. Of course, by this time, the ice cream melted. Even worse, of course, the mom was obviously distraught. When she finally got home, the whole family was anxious to hear where she had been, and when they heard what had happened they were sorry to hear of her experience. But they were all aware of the PRINCIPLES OF Latent Cause Analysis and jumped right into it as follows:
First, as soon as mom rested a bit and was ready to talk about what had happened, the whole family got together and sat around the table. They talked about the incident and HOW it had happened.
They all heard that the car had STALLED at the traffic light, and then each had remembered that the car had been STALLING for a number of weeks – each time getting a bit harder to start. Everyone remembered smelling GASOLINE when trying to start the car. Although the family couldn’t agree on the CAUSES of the stalling, they certainly could agree that there were some things about THEMSELVES that contributed to the mom’s dilemma.
That, dear reader, is the essence of Latent Cause Analysis -- seeing yourself as part of the problems around you instead of blaming other people and things.
Let me make it perfectly clear that in a Latent Cause Analysis, the first thing that’s usually focused on is the HOW, or the PHYSICS of the event. I’m going to skip that part of the Latent Cause Analysis for the purpose of this article to focus on WHAT’S DIFFERENT about Latent Cause Analysis, and what’s different is TWO QUESTIONS:
The first question this family would answer is "What is it about the way we ARE that contributed to this event," starting with the words “WE TEND TO…… “ and ending with “AND WE KNOW THIS IS NOT GOOD.”
The second question, and the LIFE CHANGING QUESTION, is "What is it about the way I AM that contributed to this event," starting with the words "I TEND TO...." and ending with "AND I KNOW THIS IS NOT GOOD."
Finally, each person would be asked what they intend to do about the way they are – and state their answers in front of everyone.
Imagine doing this in YOUR home! Imagine doing this at work! Don't think it can work?
Try it! The people and organizations that have tried this are flabbergasted at the results. Listen to some of their comments at:
Monday, January 23, 2017
I don’t know about you, but I have mixed memories of merry-go-rounds.
I remember my first ride, when my dad took me to the county fair and put me on one of those HUGE horses. When the MGR started, I totally freaked out. I cried, I wanted off. Why did my daddy do that to me?
A year passed. Time for the next county fair. When my dad took me to the county fair that NEXT year, he also brought my 2 younger brothers. Well, guess what we came across. Yup – the MGR.
What do you think I did? Do you think I cried?
Naaaaa. I wanted to try it again! After all, my 2 younger brothers were watching and I wanted to look like a BIG BOY in front of them.
So my dad put me on the horse – but this time I was prepared. I knew what to expect. It would start going round and round so I braced myself, and YES! I can handle this!!
But then I noticed the pole I was grabbing. I never really paid too much attention to it before. I followed it up to see where it went. When I looked up, I saw all kinds of crankshaft mechanisms pumping and churning. Up and down, up and down. Well the up and down motion of the cranks in combination with the rotation of the MGR made me dizzy. VERY DIZZY! I started crying again. Daddy, daddy, take me off this thing.
I can’t wait to get back on that stinkin thing. I got on it, my brothers were watching. I grabbed the pole. I intentionally looked up. YES! I can do this! CONQUERED!!!
My dad noticed what I was doing well, so he said to me “well Bobby, since you’re feeling so comfortable maybe you’re ready for THAT!”
And he pointed to this stationary ARM-looking-thing that was off to the side of the MGR. He said, “now Bobby, if you lean way over you might be able to pull the ring out of the tip of the ARM. And if you do, you’ll win a free ride!”
Every revolution, I reached more, and more and more. Finally, YES! I got the ring. I almost fell off, but I got the ring!
Human nature. Fascinating. Always reaching for more. Never satisfied with the status quo.
Isn’t it interesting that hardly anyone rides MGR’s anymore? What used to be a thrill 50 years ago is NOTHING – absolutely NOTHING today.
What does this mean about ourselves? Where is all of this leading? What does it imply about our true willingness to be "safe."
Just thinking, that’s all.