A long-term part of Failsafe's approach to Latent or Root Cause Analysis (at least since 1994) has been my insistence on the need for a Mother-Source the help drive the process.
Although not a very "manly" phrase, those who understand its intent and agree with its purpose insist on using it. In this respect, the phrase is almost like a litmus test to see who is qualified to drive the process that Failsafe has been promoting. If you understand, and buy into the overall intent of Latent Cause Analysis, you will appreciate being part of a Mother-Source.
For those who have not been exposed to Failsafe's approaches, the Mother-Source is a nurturing group of people (thus the phrase Mother-Source) bound together by a passion for ingraining a "latent cause mentality" within their workforce.
A "latent cause mentality" is one in which everyone, everywhere (all levels) has a keen desire to see themselves as part of their problems (whatever the problem), rather than blaming things on other people and things.
The Mother-Source ought to be organizational immune system's response to the BLAME VIRUS.
Thursday, January 28, 2010
Wednesday, January 27, 2010
Open Mother-Source Forum
In December, 2009 I announced my desire to facilitate an Open-Mother-Source (OMS).
Several of you have responded favorably to this idea, so I will take it to the next step. I do have a initial "vision" for this, but I will as open an possible to go wherever the membership takes us.
As I presently see it, the OMS is to be a periodic web-based meeting for people who are interested in promoting latent cause analysis at their place of business. Our primary objective will be to "promote and advance the cause," where we will define "the cause" together.
A secondary objective will be to demonstrate the intent and effectiveness of the Mother-Source concept, as promoted by Failsafe. As most of you know, the Mother-Source provides the energy for inculcating a latent cause mentality within the organization, is the keeper of the process, as well as the organization's immune-system response to the BLAME VIRUS.
This will not be a series of Failsafe training sessions, nor an attempt to sell Failsafe services. It is a genuine attempt to "practice what we preach" by working together with a larger group of people to address key obstacles to growth in this field.
This will be a free service, provided by Failsafe (at least initially).
This new, OMS forum will be open to anyone who meets the following criteria:
avoid re-inventing the wheel by tapping into what others have done.
out of the box (company box) place to ask for help and give guidance
potential source of help and energy to address existing obstacles
witness the intent and power of a "mother-source" in action
become part of something bigger, because none of us is as smart as all of us
place to vent frustrations to Failsafe -- and for Failsafe to HEAR them -- for eventual improvement of the ROOTS process or resolution of obstacles
published minutes
scheduling, promotion, moderation of meeting by Failsafe
Several of you have responded favorably to this idea, so I will take it to the next step. I do have a initial "vision" for this, but I will as open an possible to go wherever the membership takes us.
As I presently see it, the OMS is to be a periodic web-based meeting for people who are interested in promoting latent cause analysis at their place of business. Our primary objective will be to "promote and advance the cause," where we will define "the cause" together.
A secondary objective will be to demonstrate the intent and effectiveness of the Mother-Source concept, as promoted by Failsafe. As most of you know, the Mother-Source provides the energy for inculcating a latent cause mentality within the organization, is the keeper of the process, as well as the organization's immune-system response to the BLAME VIRUS.
This will not be a series of Failsafe training sessions, nor an attempt to sell Failsafe services. It is a genuine attempt to "practice what we preach" by working together with a larger group of people to address key obstacles to growth in this field.
This will be a free service, provided by Failsafe (at least initially).
This new, OMS forum will be open to anyone who meets the following criteria:
- must be either a corporate employee or Licensed Failsafe Affiliate
- must not be a competing consultant
- must have a passion for helping one another (ourselves included) see themselves as part of our problems, rather than blaming things on other things or people
- must be willing to work with other Open-Mother-Source-Central members to advance the cause
- must be willing to further define the cause
- must strive to attend all web-based meetings
If you meet the above criteria, and want to be part of something bigger, please join us.
DATE of 1st Meeting: Thursday, March 18, 2010.
TIME: 1:00 PM - 3:00 PM Eastern
PLACE: Your computer, via GoToMeeting (scheduled by Failsafe
TO REGISTER: Click to join the Failsafe-OMC YahooGroup. You will be asked some qualifying questions (to avoid the SPAMMERS). As soon as I see that are admitted to the group, I will send informattion about how to gain access to our web-based meetings. Note: Your membership in this group is totally within your control (you may leave whenever you wish).
MORE INFORMATION: on Failsafe's web site
Thursday, January 21, 2010
FORCED to learn from things that go wrong??
Sometimes I wonder about the intentions of companies who are doing "root cause analyses." I wonder why they are doing them. I remember that in the early days (1970's), suggesting that people do a root cause analysis was like suggesting that they get a root canal. Few, if anyone in the industries that I was serving (mainly chemicals) seemed very interested.
Then along came OSHA 1910, and all the Process Safety Management (PSM) requirements. To be honest, I didn't even know that these requirements were being developed until 1992, when concurrent to their introduction my business started booming. I have been a fortune recipient of these requirements ever since.
Or have I?
Sometimes I wish I would not have chosen the professional path I am on (root cause analysis), because it highlights parts of the human condition that are hard to accept, and even harder to deal with. Sometimes it's easier to be ignornant than to be comfronted with a difficult truism.
For example, many of us who have dedicated our professional lives to the advancement of "root cause analysis" have learned that the catastrophic events that precipitated the above-mentioned PSM requirements were caused by a cueing-up of unresolved small problems. In other words,
Big problems are caused by unresolved small problems.
At one time, I wondered if those of us in the "root cause analysis business" were the only ones that knew this. Or, I wondered, does everyone inherently know this but would rather not acknowledge it?
The answer to this question came rather bluntly to me about 2 years ago in the mid-west, where I was training a group of maintenance people in the principals of root cause analysis (or latent cause analysis, per Failsafe). When I stated the above eureka, i.e., that big problems are caused by unresolved small problems, I felt like I had unleashed a pack of rabid wolves! The maintenance people told me, rather crudely, that:
Why do our companies sit back and wait for big things to go wrong, and then do their root cause analyses -- even when the results of these large investigations seem to always point to the same truism: big problems are caused by unresolved small problems.
Why do companies spend a lot of money to train their people in an investigative method so that they can wait for a big problem to occur (in order to investigate it)?
Why don't these same companies require their trained people to use their training on the small problems occuring in their work lives? Wouldn't it be better to learn from our small problems so that we can avoid the big ones?
Why do so few people seem interested in learning from things that go wrong?
Do we have to wait for OSHA (or someone else) to FORCE us to do what we ought to have been doing all along?
More importantly:
Then along came OSHA 1910, and all the Process Safety Management (PSM) requirements. To be honest, I didn't even know that these requirements were being developed until 1992, when concurrent to their introduction my business started booming. I have been a fortune recipient of these requirements ever since.
Or have I?
Sometimes I wish I would not have chosen the professional path I am on (root cause analysis), because it highlights parts of the human condition that are hard to accept, and even harder to deal with. Sometimes it's easier to be ignornant than to be comfronted with a difficult truism.
For example, many of us who have dedicated our professional lives to the advancement of "root cause analysis" have learned that the catastrophic events that precipitated the above-mentioned PSM requirements were caused by a cueing-up of unresolved small problems. In other words,
Big problems are caused by unresolved small problems.
At one time, I wondered if those of us in the "root cause analysis business" were the only ones that knew this. Or, I wondered, does everyone inherently know this but would rather not acknowledge it?
The answer to this question came rather bluntly to me about 2 years ago in the mid-west, where I was training a group of maintenance people in the principals of root cause analysis (or latent cause analysis, per Failsafe). When I stated the above eureka, i.e., that big problems are caused by unresolved small problems, I felt like I had unleashed a pack of rabid wolves! The maintenance people told me, rather crudely, that:
"You've been hired to come in here and tell us THAT? Is this some sort of revelation to you? Maybe you should sit down and let us teach you a thing or two. We've been trying to point this out for years and years! How dare you come and preach to us!
Why do our companies sit back and wait for big things to go wrong, and then do their root cause analyses -- even when the results of these large investigations seem to always point to the same truism: big problems are caused by unresolved small problems.
Why do companies spend a lot of money to train their people in an investigative method so that they can wait for a big problem to occur (in order to investigate it)?
Why don't these same companies require their trained people to use their training on the small problems occuring in their work lives? Wouldn't it be better to learn from our small problems so that we can avoid the big ones?
Why do so few people seem interested in learning from things that go wrong?
Do we have to wait for OSHA (or someone else) to FORCE us to do what we ought to have been doing all along?
More importantly:
Do YOU wait for someone to require YOU to do what YOU know YOU ought to have been doing all along?
Monday, January 18, 2010
The death of Root Cause Analysis (at least for Failsafe Network)
Two years ago, in January 2008 I decided to listen to Failsafe's 4-day "Root Cause Experience" class attendees and change the name of Failsafe's pursuit from "Root Cause Analysis" to "Latent Cause Analysis."
Class attendees pointed out a fact about Failsafe's approach to "root cause analysis" which made the phrase counter-productive. Since Failsafe's methods do not identify "root causes," why use the phrase "root cause analysis?"
That's right -- Failsafe's approach to "root cause analysis" does not identify root cause! Instead, Failsafe's methods address the Physical, Human, and LATENT Causes.
Therefore, Failsafe Network, Inc. is now teaching, mentoring, and leading organizations towards doing Latent Cause Analysis.
Let me explain.
Think of anything that exists within nature -- mountains, oceans, trees, grass, bees, birds, even human beings. Scientists have done their best over the years to understand how all these things "came to be." They (scientists) attempt to understand the physical causes (reasons, factors) that explain our existance. In general, then, as humans we strive to understand the physical reasons for what we see. It seems innate within us that we yearn for this understanding.
Now shift your thoughts to things that we, as humans, create. Let's say we build a foot bridge over a creek. Just as with "nature," there is a physical explanation for the existance of the foot bridge. But since human beings put it there, there are also "human causes" (reasons, factors) that exist. After all, the foot bridge didn't simply appear (as did the mountains, oceans, grass, bees, etc.). Human beings put it there. It becomes their responsibilty.
Now let's introduce "things that go wrong." Let's say the footbridge collapses while someone is walking across. When something like this occurs, all that has been said remains true. We can initially strive to understand the physical causes (reasons, factors) of the collapsed foot bridge. But then, since the foot bridge was put there by human beings (and is therefore their responsibility), we also ought to understand the human causes (reasons, factors). We need to know "who did what wrong" (or, what were the points of inappropriate human intervention) that enabled the physics.
This is not to say that these human beings are "bad," or even that they knew they were doing something inappropriate. In fact, most of the time they didn't know. That's how we learn -- we go through life, doing the best we can each moment that presents itself until WHAM -- something goes wrong. Then, looking back at it (in retrospect, using 20/20 hindsight), we can see what we did (or didn't do) that enabled the physics.
But why do people do what they do? Why am I taking time to write this short article on this blog? Why did I get up this morning at 5:00 AM, when I was so comfortable under my bed covers? Why did I mess up my driveway when I plowed the snow off of it this winter?
If all we do is identify and act on the physical and human causes (reasons, factors) of our problems, then all we've done made sure the last incident will not happen again (the fallen footbridge, for example). And although there's nothing wrong with making sure the last incident will never happen, that's not enough. In fact, only going this far will cement you into a totally reactive existance -- just waiting for new (and more catastrophic) things to go wrong in your life.
Things go wrong in our lives to teach us something about ourselves. When we see the truth about ourselves, we change. When we change, our future (and the futures of those around us) will change -- for the better.
Therefore, the thrust of Failsafe's approach (Latent Cause Analysis) is to first understand the physics, and then understand the human interventions, but then to address the latent causes of the event.
I will write much more about latent causes in a future post. For now, let me give you the bottom-line Failsafe definition of a latent cause. The latent causes of an event are the answers to two questions:
1. What is it about the way WE ARE (as a family, business unit, organization, etc.) that contributed to this event?
2. What is it about the way I AM (as an individual) that contributed to this event?
When a person sincerely answers question #2 (above), it'll change their life. Things go wrong in our lives to teach us something about OURSELVES.
When people change, everything else changes.
Class attendees pointed out a fact about Failsafe's approach to "root cause analysis" which made the phrase counter-productive. Since Failsafe's methods do not identify "root causes," why use the phrase "root cause analysis?"
That's right -- Failsafe's approach to "root cause analysis" does not identify root cause! Instead, Failsafe's methods address the Physical, Human, and LATENT Causes.
Therefore, Failsafe Network, Inc. is now teaching, mentoring, and leading organizations towards doing Latent Cause Analysis.
Let me explain.
Think of anything that exists within nature -- mountains, oceans, trees, grass, bees, birds, even human beings. Scientists have done their best over the years to understand how all these things "came to be." They (scientists) attempt to understand the physical causes (reasons, factors) that explain our existance. In general, then, as humans we strive to understand the physical reasons for what we see. It seems innate within us that we yearn for this understanding.
Now shift your thoughts to things that we, as humans, create. Let's say we build a foot bridge over a creek. Just as with "nature," there is a physical explanation for the existance of the foot bridge. But since human beings put it there, there are also "human causes" (reasons, factors) that exist. After all, the foot bridge didn't simply appear (as did the mountains, oceans, grass, bees, etc.). Human beings put it there. It becomes their responsibilty.
Now let's introduce "things that go wrong." Let's say the footbridge collapses while someone is walking across. When something like this occurs, all that has been said remains true. We can initially strive to understand the physical causes (reasons, factors) of the collapsed foot bridge. But then, since the foot bridge was put there by human beings (and is therefore their responsibility), we also ought to understand the human causes (reasons, factors). We need to know "who did what wrong" (or, what were the points of inappropriate human intervention) that enabled the physics.
This is not to say that these human beings are "bad," or even that they knew they were doing something inappropriate. In fact, most of the time they didn't know. That's how we learn -- we go through life, doing the best we can each moment that presents itself until WHAM -- something goes wrong. Then, looking back at it (in retrospect, using 20/20 hindsight), we can see what we did (or didn't do) that enabled the physics.
But why do people do what they do? Why am I taking time to write this short article on this blog? Why did I get up this morning at 5:00 AM, when I was so comfortable under my bed covers? Why did I mess up my driveway when I plowed the snow off of it this winter?
If all we do is identify and act on the physical and human causes (reasons, factors) of our problems, then all we've done made sure the last incident will not happen again (the fallen footbridge, for example). And although there's nothing wrong with making sure the last incident will never happen, that's not enough. In fact, only going this far will cement you into a totally reactive existance -- just waiting for new (and more catastrophic) things to go wrong in your life.
Things go wrong in our lives to teach us something about ourselves. When we see the truth about ourselves, we change. When we change, our future (and the futures of those around us) will change -- for the better.
Therefore, the thrust of Failsafe's approach (Latent Cause Analysis) is to first understand the physics, and then understand the human interventions, but then to address the latent causes of the event.
I will write much more about latent causes in a future post. For now, let me give you the bottom-line Failsafe definition of a latent cause. The latent causes of an event are the answers to two questions:
1. What is it about the way WE ARE (as a family, business unit, organization, etc.) that contributed to this event?
2. What is it about the way I AM (as an individual) that contributed to this event?
When a person sincerely answers question #2 (above), it'll change their life. Things go wrong in our lives to teach us something about OURSELVES.
When people change, everything else changes.
It's been a long, long time
It's been quite a while since I last posted to this blog -- and one of the things I'll be trying to do this year is post much more frequently.
So starting this month (January, 2010), I'm going to be sharing what I am thinking about, relative to Latent or Root Cause Analysis.
If any of you who read this blog would like me to share my thoughts about anything in particular, please let me know. Either respond on this blog, of write me a personal email.
So starting this month (January, 2010), I'm going to be sharing what I am thinking about, relative to Latent or Root Cause Analysis.
If any of you who read this blog would like me to share my thoughts about anything in particular, please let me know. Either respond on this blog, of write me a personal email.
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