It is admittedly gratifying to experience the energy and enthusiasm that accompanies almost all 4-day Latent Cause Experience Classes. It is even more satisfying when I get letters from some of you to tell me of some personal changes that you've made because of the key question:
What is it about the way I am that contributes to my problems?
It'd be easy to "pat myself on the back and say GOOD JOB, Bob."
But that's not how life works, is it?
I don't know about you, but every time I think I'm on top of things, the rug gets pulled out from under me. Sometimes, it comes from the mouth of a client, other times a pitiful seminar performance.
This time, it's been different.
Over the past year, I've had the chance to review more than my normal share of Latent Cause Analysis Reports. I usually see many Mini-LCA's (you send them in order to receive your attendee certificates). But 2009 was different. I've reviewed dozens of your reports, and
The official investigative reports that most of you are writing are very inconsistent (depth, terminology, and format), even within the same site.
Unfortunately, your investigative efforts will be judged based on the reports that you write.
Please understand, that the effectiveness of Failsafe's training will also be judged based on these reports (GULP)!
Although a Latent Cause Analysis can be ultimately successful without ever writing a report, and although an LCA can be an absolute failure and still produce a stellar report, it is a fact that your efforts will be judged almost solely by the reports you write.
The current state of the reports that many (not all) of you are writing is not your fault. It's mine.
I have not placed enough attention to this in the products and services offered by Failsafe, but this is going to change. More than anything last year, I learned the value of consistency; consistency in appearance, quality, terminology, and depth.
For your sake, as well as mine, Failsafe and some of its affiliates are working on a web-based template to guide you through a Latent Cause Analysis. It will require the user to supply specific kinds of information, in a specific order, to help you do a proper ROOTS-based investigation and to generate consistent reports.
Stay tuned................................
3 comments:
Hey Bob,
I love this blog post! You are correct that reports have two opposing faces: they have limited value toward changing the work culture, since very few people actually read the official finished "report". However, the overall quality of the investigation is often judged by the quality of that same official report. Worse yet, the company lawyers and others in management spend much time and effort "scrubbing" the official report of any conclusions or information which could put the company at a disadvantage if there should ever be litigation (from government regulators, citizens, employees, etc.) in response to an incident - since the official report is discoverable evidence. What to do, what to do...
I believe there are solutions to this problem, in terms of wording and other ways to overcome these difficult barriers. But I will say that so many investigators get thoroughly frustrated at this point of an investigation. They have completed the real work, discovered the important issues, made presentations to stakeholders, gotten buy-in and agreements on action items, etc. But now that friggin' report needs to be done and nobody will cooperate on what stays in, how it is worded, and what gets edited out. Plus there are deadlines to complete the investigation, and the investigation is not done until the report is finalized and approved. It is a real mess.
I love the idea of a web-based report template. My thoughts are that it could be used by investigators to structure, format, and document the findings of the investigation in terms of physical, human, and latent causes. Within the on-line system the report could be "anonymous", such that it is not subject to legal review or "discovery" during any future litigation that could occur. The only priority is an LCA technical review to be sure the report and conclusions are sound and properly presented. And then the findings from one company and one investigation can be shared with all of your affiliates and others who participate in your forums, such that industry-wide sharing and learning can be promoted.
For the investigator contributing to the on-line report there is the benefit that the information from the investigation is well organized and technically sound. Then if the "official" internal company report is heavily edited at least the investigator will not feel as if important findings are brushed aside. I also believe those assisting with the on-line report can also assist with how to navigate the legal and political issues faced with producing the "official" report - such that some careful wording of the findings can contribute toward less of the "good stuff" gets cut from the final report.
Maybe this could be one of the missions of the OMS forum?!?
Overall, I think this is a fantastic idea.
Mari,
Your response has been phenomenal -- borderlining on a breakthrough. You've taken my thoughts were they have never been before.
I especially appreciate your ideas concerning anonymity. But let me make sure I understand.
You are proposing that Failsafe set-up a web-based reporting system where anonymous results can be shared. All reference to company, site, or anything that can be litigous later-on can be omitted.
But what about the company-specific reporting requirements? How do you propose dealing with them?
Do you foresee a similar, but private company web-based reporting system?
Thanks Mari.
Bob,
First, sorry for signing in to my wife's iGoogle account prior to typing the previous message. She has her page set up with "puppy of the day" and news headlines that I like to check - and I forgot to sign out before I sent the message. I will probably do this again some day, so just remember that "Mari" is really me.
Regarding company reporting - I don't expect significant changes any time soon. As long as companies believe they will be "punished" for honest introspective information that they volunteer there will be a reluctance to publish the really controversial findings from investigations. I am not saying this is correct, but only that it is reality. I sense this is changing slowly over time, but veeeerrrryy slllooooowwwwly!
So I guess I am not thinking in terms of a company-specific web-based reporting system. Just a global information sharing and learning system that could be anonymous and not put companies in jeopardy due to honest introspection.
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