Wednesday, March 24, 2010

Zero-Based Root Cause Analysis (2)

It is probably true that you will never learn anything that someone else didn't already know. If this is true, then shouldn't we spend a lot of time learning from other people? Let's explore this a bit....

Before I was born, people knew how to walk, talk, eat, etc. And then, I was born.

I know how I learned to walk, to talk, to speak in public, to write, to breath, to comb my hair (what’s left of it). I had to fail, and fail, and fail, and fail. So did Edison. Sometimes, failing leads people to understand that “hey, I ought to learn more from other people.” Other times, failing leads people to “hey, those other people were dead wrong!”

Failure is the only phenomena of life capable of changing the way we see things, if we’re willing to put aside “the shell.” We never know where “failure” will lead us.
Maybe the real issue here is within the word “learn.” Learn is too vague a word, at least for me.

One of the synonyms for “learn” is “discover.” Something special happens at the moment of discovery. It’s the “epiphany” that I seek, and that I’m interested in helping others seek. Eureka! Shock! Mind-blowing, life changing, instantaneous paradigm change! It’s really hard to get to that point when someone else does the thinking for you. In fact, you can’t. When someone else does the thinking for us, we turn into lemmings.
Nevertheless, I suppose it’s true that I've not learned anything that someone else didn’t already know. But the most important things in life are the things that change me (us). And these kinds of things can only be learned by personal discovery.

I am not saying that I don’t think we should learn from one another. Of course we should! If we don’t we’re doomed.

And am I not saying that codes, standards, checklists, and all of that are bad. I think they’re essential. Without them, we have "Haiti."

When any of us learns something, we should all do our best to apply those learning’s across the board – before an incident occurs.


Those learning’s are our past solutions to past problems that we should have already have applied to our lives.

When we have a current problem, it’s time to put our past solutions to the side (until we know how and why the event occurred). I’ve done this all my professional life, and it’s led me (and others) to places I’ve (we’ve) never imagined.

All the ancient books (and religions), all the past philosophies, all our current knowledge, all that’s in our text books and on the internet will not replace the need for me (each of us) to learn certain things myself (ourselves)– even if someone else already knew – as a result of something that has gone wrong.

Before the problem, learn from others. After the problem, forget what others learned and simply wonder “why it happened to me (us), especially if others knew better?” In the end, it’s a very individual, lonely, but breathtakingly ecstatic existence – if we’re willing to break out of the shell.

Zero-Based Root Cause Analysis (1)

I recently viewed a slide show about Foreign Material Management, i.e., making sure the wrong stuff doesn't get into our systems. It was based on learning's from past investigations, and was an excellent slide show.

We have learned an enormous amount about why things go wrong through investigating past incidents. Obviously, it is imperative to share what we've learned so that others do not experience needless pain.

As I was viewing the slide show, however, I remember thinking that there’s a difference between what we've learned, and how we've learned it -- a huge, monumental, life-shattering difference! Unfortunately, it seems that many people confuse the two.

Let's suppose, for example, that you have never eaten with with chopsticks. If you went to an oriental restaurant and were unable to use them on the first try, you would probably try another time, and then another until you were finally able to eat. In this simple example, you learned how to use chopsticks by trial and error.

Now let's suppose that you wanted to take your child to the same oriental restaurant, and you wanted him to avoid the frustration you had. You would most probably teach your child how to use chopsticks, based on what you've already learned. I think this would be good, responsible parenting.

We learn from our failues, and then we teach other people how to avoid that same failure. This is life. This is "being responsible." This is good.

But let's suppose your child couldn't use the chopsticks even after you taught him! The tendency, in this simple example, would be for you to compare what he was doing with what you told him to do. "Is he holding the chopsticks the way I suggested?"

We tend to investigate things that go wrong by comparing what went wrong with our predetermined understanding of "correctness." What if our predetermined understanding or correctness is invalid?

In the chopstick example, what if your adult hands were able to hold the chopsticks in a way that was impossible or ineffecitve for your child's smaller hands? Wouldn't it be better to simply look at the evidence in front of you, in this case your child trying to eat with chopsticks, with an open mind about what's going wrong. Even more, might it not even be better to let your child struggle a bit on his own? After all, he might invent a better way?

When we use our past learning’s as a basis of “goodness” when investigating an incident, I believe we’ve biased ourselves in the utmost manner. After all, what is bias? Isn’t it a “preconceived notion?” Isn’t bias the number 1 (or close to it) obstacle to learning something NEW? There’s a difference between how to learn, and how to apply those learning’s. We mix them up all the time.

Is it possible to do a root cause analysis without any reference to our past learning's?

I say YES! Not only do I say YES, I also say this is the ONLY way to grow -- to see what we've never seen, and go where we've never gone.

Beware of those who are asking you to compare what went wrong with a predetermined understanding of correctness.

More later..........