Monday, March 06, 2017

It's Not Our "Systems," It's Ourselves

One of the most life-changing experiences I’ve ever had was while working at Morton Thiokol in the winter of 1986.  I was working there as a root cause analysis consultant when the Challenger exploded and was there while the incident was being investigated.   Because I was there, I suppose, I became more engrossed than most people in the causes of the event.

This one event SINGULARLY ripped me out of my purely engineering shell and THRUST me into the realm of the human behavior. 

I don’t have time to share the whole story in this short vlog, but I would like to challenge you with a few questions to help you understand some of the underlying causes of the event.  I’ll ask you 7 questions.  

As I share theses questions, please ask yourselves what it is that REALLY causes our problems?  Is it systems, or is it us?

Here are the 7 questions:
  1. Have you ever gone forward with any kind of endeavor IN SPITE OF an anomaly popping up that you didn’t quite understand?  Ever?
  2. Have you ever been called “unreasonable” in the past, and were in the midst of trying to correct that impression when another situation occurred where all the players were ready to “go” except yourself?  In other words, have you ever tried to be “reasonable” in a risky situation?  
  3. Have you ever gone by the book even when you were suspicious that the book was not good enough in this instance, because if anything does go wrong, you can point back to the book and say “I was only following procedure!” Ever?
  4. Have you ever done something risky because you did it before and got away with it?
  5. Have you ever ignored your gut feelings when they told you to be more careful, even though the data said you were okay?
  6. What do you do when you ask someone for their advice and you don’t like their answer?  Do you ever argue with them, or try to change their minds?  Why?  Why ask in the first place if you’re not willing to hear the answer!
  7. Now let’s turn it around.  What do YOU do when someone asks YOU a question and they don’t like YOUR answer?  Do you back down and let them persuade you that they are right?  Before you say “no, I’d never do that,” let me ask you this.  What if it was your boss, or the client who said something like “either change your answer or we’ll find someone else?”

I wish I could see your faces when you read these – and I also wish you’d dwell on each of these a long, long time – because almost all of us are guilty of almost all of these!  These are the kinds of things that caused the Challenger disaster.  

So here’s the point.  Are any of the things I’ve mentioned SYSTEM-type causes?  You know, procedural, or checklist, or work-flow related?  That’s what most root cause analysis methods suggest – that our problems are caused by our SYSTEMS.  Is that true?

Naaaaaaa…….  NASA and their contractors probably had the best systems in the world, and look what happened in spite of their systems.

It’s not our systems that cause problems – it’s US – our attitudes, beliefs, assumptions, and tendencies.  Each of us.  All of us.

When small things go wrong in your life, ask yourself "what is it about the way I am that contributed to this incident, and what am I going to do about it?"  Ask yourself this question over and over, each time something small goes wrong in your life.

You just might avoid the killing or maiming of yourself, your loved ones, your friends, and your neighbors.

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