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:

"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?