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.
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.
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.