Slow Down!

While presiding over a fascinating 4-hour discussion, an upper-level manager asked in exasperation:

What, exactly, do you mean when you say that I have to SLOW DOWN!

The 4-hour discussion was prompted by two Root Cause Analyses that were presented by their Principal Investigators (PI's) to a group of 30 people who had just gone through 4 days of Root Cause Analysis training. Amongst the trainees were operators, maintenance people, technical resources, and managers. The recently-trained people were surprised at what was presented by the trained PI's, and especially at their answers to some of their questions.

Why didn't you follow the approach suggested in the training? Why did you take so many shortcuts? Why did you leave-out the most important ingredients of a successful investigation (keeping the 3 vectors of evidence separate, and requiring the stakeholders to come to their own conclusions).

As the PI's listened to the criticism, they became a bit emotional. After being more-or-less attacked by the recently-trained group, one of the PI's stood up and said:

You have no idea of how difficult it is to do the things we've been taught in the classroom. The methods are easy, and the concepts are sound. But getting the required resources and time is almost impossible.

The impassioned plea from the PI's lasted about 30 minutes. The essence of their argument was that management is not interested in truly understanding why things go wrong. They're too focused on goals and objectives. They're going fast, and they want to go faster. After they finished their rebuttal, about 25 of the attendees loudly applauded!!!!

As I said, managers were in attendance. They had been part of the 4-day training. One of them was a Plant Manager. Sitting in silence, listening first to the attacks and then to the PI's as they defended themselves, and finally after hearing the applause, the Plant Manager asked a pointed question:

What, exactly, do you mean when you say that I have to SLOW DOWN! Can you tell me what you'd like me to do? What would you like me to change? How would you like me to act?

The group's response was interesting. One fellow tried to explain WHY it was important to slow down. Another person said "you shouldn't have to ask that question because you've taken the same training as us!" Another suggested that "slowing down is a matter of attitude, more than it is action."

As I listened to the Plant Manager's question, and then the attendees answers I tried to put myself in her shoes. I immediately understood. What DO we mean when we ask each other to slow down? Why do we always expect the OTHER person to do the "slowing down" instead of asking ourselves the same question?

What, exactly, do we mean when we say we ought to slow down?

Any ideas?

(please post them)

Do you WANT to be on the Merry-Go-Round?

I am bothered, and this is my place to vent. My feelings come from some recent comments coming from the www.rootcauselive.com forum.

An unnamed organization revealed that even after experiencing some very well-received Root Cause Analysis training it is struggling to inculcate a root cause mentality. The organization asked for advice.

I requested that forum members suggest specific, actionable items to help this organization move in the right direction. I summarized people's ideas, then asked everyone to vote on their 3 favorite. 58 people voted -- one of the most popular of all our polls. But I was shocked at some of the results.

The suggestion that received the most votes was no surprise. In fact, I was glad to see it!

Insist that management issue objectives, responsibilities, policies and procedures supporting the RCA effort. Set specific objectives in people's performance reviews relating to RCA, especially for those who will have to do RCA's. Expectations, milestones, incentives, and rewards must all be delineated.

It was the second-place suggestion that caught my attention:

Internalize RCA in your company. Have mentors that will train others, as well as lead company RCA's. Do not be dependent on outside consultants when something goes wrong.

At first glance, there is nothing alarming at this statement. In fact, inculcation depends upon internalizing the RCA effort. But as comments continued to trickle-in, I began to see a major problem -- especially after a respected forum contributor STRONGLY suggested that it is best for an organization to align itself to someone offering train-the-trainer packages to minimize training dollars as well as dependency on the trainer/consultant.

It's important to note that this item received the second-most votes of any any item. About half the voters voted for this item. In other words, this is not the whim of one person, but an opinion of many "rooticians."

In the following paragraphs, I'm going to say some things that have been presented to about 1500 people over the last 2 years. These comments have been made in seminar-form, as part of an overview lecture about Root Cause Analysis and have been overwhelmingly agreed-upon from the people who operate, maintain, and manage our industrial facilities.

We are on a Merry-Go-Round!

We are spinning round and round but to a large degree going no-where. The Merry-Go-Round spins faster and faster as the years go by, consuming us all in the useless endeavor of "holding on," while we should/could be doing other things. Carl Jung said:

Our intellect has created a new world that dominates nature, and has populated it with monstrous machines. The latter are so indubitably useful that we cannot see even a possibility of getting rid of them or our subservience to them.

In spite of our proud domination of nature, we are still her victims, for we have not even learned to control our own nature. Slowly but, it appears, inevitably, we are courting disaster.

As any change must begin somewhere, it is the single individual who will experience it and carry it through. The change must indeed begin with an individual; it might be any one of us. Nobody can afford to look round and to wait for somebody else to do what he is loath to do himself.

Few people will want to see the Merry-Go-Round -- very few.

If you don't like the Merry-Go-Round analogy, consider the Leaning Tower of Pisa. To one extent or another, we were all born on a leaning tower. We have never stepped-foot off the tower and never had any visitors. There are no windows or doors. We live on the tower with 10,000 other people. We are all on this leaning tower, to varying degrees.

Now, let's get back to the voting I was discussing in the beginning of this article. The problem, as apparent from the voting, is that most people don't want to see the leaning tower.

One of the most common investigative principles is to use outsiders to lead investigations, because they can see things that insiders either cannot or are unwilling to see. Outsiders are not on the same Merry-Go-Round, or in the same Leaning Tower as the insiders. Outsiders have little or no political stake in the investigative findings. Outsiders are more likely to help people see their own leaning tower.

Of course, organizations cannot afford to wait for a catastrophe, and then call-in an outsider to investigate it! How, therefore, can an organization internalize its effort and still remain unbiased. In other words, how can someone who is on the leaning tower acknowledge that he's on it before it causes a problem?

It is not easy! That's the point of this article! Every organization ought to have clear, established ties to outsiders -- people that can help them see themselves as they are.

It is a mistake for an organization to purchase a train-the-trainer package from a consulting group, then tell them to go away! As a consultant and trainer, I know that organizations pick and choose what they want to embrace from the training that I provide. This is very frustrating because "it's the whole thing that works, not bits and pieces of the whole thing!" I cannot image what would happen if I trained 10 trainers, who in turn pick and choose what they think is important, who in turn train another 100 people, who also will pick and choose!

So here's the bottom-line, as least as I see it. Helping people learn from things that go wrong depends on courage, insight, and desire -- traits not often found in our fast-paced world.

...It is the single individual who will experience it and carry it through....

Root Cause Analysis is NOT just another program or tool. It is a way of seeing -- something that can change a person's life. It can help us see the Merry-Go-Round. Please don't treat this subject lightly. Please have continuous ties to outsiders; people who can help you see things that you cannot see. Certainly, you ought to acknowledge those in your own organization that are drawn to this endeavor. That's how to inculcate the effort at your site. But make sure they are connected to outsiders also -- to help them remain as pure as they can be in seeing the causes of their problems.

Do Managers Know what Root Cause Analysis Really Is?

When I am hired to teach Root Cause Analysis to an on-site group of people, one of the most common questions I hear is "does our management know what you're teaching us?" My generic answer is "no!" In my experience, most managers and executives think that Root Cause Analysis is something done by engineers and other technically-inclined people on either complex, long-term problems or the sudden disasters that all of us dread. They don't think it's necessary to attend the training themselves, since they don't think they'll be involved -- other than in a support role.

Twice in my career, however, I have had the "management team" sit through one of my 4-day classes. The first time this happened, about 5 years ago, it was a resounding success. The management team realized that Root Cause Analysis was much more than they imagined. They quickly got on-board and supported a refinery-wide effort.

The second time, however, was not as encouraging. In retrospect, I fear that this second "data-point" might be typical.

I knew I was in trouble after the 1st hour. Blank, glazed eyeballs stared me in the face. By lunchtime, I saw them huddled together discussing whether or not to cancel the training. At quitting time on the first day, the Human Relations manager approached me and said:

I am getting absolutely nothing out of this and will probably not come back tomorrow unless you can convince me that I should. I cannot see how I can possibly benefit from this, or how I could apply it in my world.

I looked at this person in disbelief and asked, "Didn't you say you were the HUMAN RELATIONS manager? You cannot see how you can relate to this???"

My disbelief stemmed from the fact that much of the first day was spent on the human-side of Root Cause Analysis, including how important it was to get everyone involved in "root cause thinking," but how difficult that would be in an environment of fear. I also tried to challenge their perception of Root Cause Analysis (as I do in all my classes), but as the saying goes:

Some people listen but do not hear.

How true! How true! Blogs like this are where people like me can express their thoughts for others to read and then make comments. I am expressing these particular thoughts because the experience greatly moved me. After all these years of trying to encourage the lower-level people to "learn from things that go wrong," I was confronted with THEIR reality, and it's worse than I thought:

Not only do most managers not know what Root Cause Analysis is, they don't WANT to know.

If the normal reaction to this seminar were the same (apathy and boredom), then I'd know that I was the problem. But I am continually encouraged and energized by class attendees -- especially attendees from the hourly ranks -- the hands-on folks who KNOW why things go wrong. They see this as a PRACTICAL way to make a REAL difference.

Why is there such a discrepancy between the way the hands-on folks see this subject (Root Cause analysis) and their managers? Why am I continually drawn towards supporting the PLIGHT of the hands-on folks -- in the face of borderline-oppressiveness from their managers?

Actually, the answer is obvious.

PS: Of course, I am not speaking here about ALL managers, or ALL organizations. There are some excellent examples out there.

Introducing the Failsafe Network BLOG

Failsafe Network is a small consulting company that focuses on organizational and individual Root Cause Analysis. It is recognized that Blogs and their syndication are the wave of the future. Therefore, this trial is being undertaken to experience the usefulness of the concept.

It is hoped that several times a week, C. Robert Nelms (President and founder of Failsafe) will contribute relavent thoughts via this Blog.

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C. Robert Nelms