IntroSpect -- an Important Concept for a People in Crisis

I have been looking at things that go wrong for almost all of my adult life, and I have been drawn deeper and deeper into this fascinating field almost daily.

Looking back, however, I think the most significant thing I've learned as I've confronted the many issues surrounding the "failures" of our lives is the need for:

INTROSPECTION instead of BLAME

As you continue reading, imagine a world where everyone looked at themselves as part of their problems instead of blaming other people and things.

Let's say something goes wrong in your life.  It could be anything.  You could be involved in trying to launch a space shuttle, and it exploded in mid-air causing 7 people's death.  You could be mayor of a city with staggering murder statistics.  You could be a hospital administrator who has just been notified of a medication error that resulted in a death.   

Or you could be a homeowner whose new drone crashed-landed.  That's what happened to me, and I'll use it as an example of what IntroSpect asks people to do.

I received a new drone for Christmas. 

A month or so after I got the drone, an incident occurred when I was flying it.  One of the propellers suddenly broke apart when it was flying and the drone crash landed.

In trying to understand the causes of my drone failure, the first thing I did was to gather a lot of evidence.  I'll not say anything more about the evidence-gathering process -- that's a subject for another blog.

After gathering all the evidence, the next thing I wanted to know was HOW the propeller broke.   They key word is HOW – a focus on the PHYSICS, or MECHANICS of the event.  

I determined that a shroud that normally protects the one of the propellers had flexed too much while aloft and came in contact with the propeller – shattering the propeller.

Please note that this would be the same step no matter what the incident:  a space shuttle explosion, a murder on the streets of a city with staggering murder statistics, a medication error in a hospital that led to a death, or whatever.  I've learned the importance of UNDERSTANDING THE PHYSICS (or how) FIRST.

Now here is where it get’s REALLY interesting.

Now that I’ve understood the PHYSICS (or the HOW), I’d now ask:

What did I do that ALLOWED OR ENABLED the Physics?

Another way of asking this question is:  who did what wrong that allowed or enabled the physics?  

In the case of the drone failure, sure at this point I could stop and simply BLAME the incident on the manufacturer.  After all, they DID have a role.  But what good does it do ME to merely BLAME the manufacturer?  Is that why this incident happened to me -- to teach me to BLAME other entities for my problems?  Am I to take no ownership whatsoever for the problems in my life?

In the case of the shuttle explosion, "who did what wrong within the shuttle launch organization?"  In the case of the murder in a city with high murder statistics, "who did what wrong within the city (administrators, police, or whoever)?"  In the case of the medicinal error in the hospital," who did what wrong" that led to this error?"

Getting back to the drone, what did I do that allowed or enabled the physics?

Well, I'll admit that I flew the drone in wind conditions that were too high! That was my role.

These kinds of "admissions" are always a part of the IntroSpect process.  And there is always more than 1 person that needs to make this kind of admission.   As I suggested before, if I involved the drone manufacturer in this process, they might have admitted “we manufactured our drones with protective shrouds that are too flimsy.”

But let’s focus on me right now so I can show you the POWER of what’s next.  Remember, I flew the drone in wind conditions that were too high!

Now here is where it get’s REALLY, REALLY interesting.

Why did I do what I did?  Why does anybody do anything?  Isn’t it true that everything we do is caused by the THOUGHTS going through our mind at the time we did it?  Think about that, and you’ll see how simple all this really is.  

So “what thoughts WERE going through my mind when I decided to fly my drone that windy day?”  Well, something like: 

I’ve been waiting to fly this drone on the Blue Ridge Parkway to get some spectacular shots ever since I got this drone.  THIS IS THE DAY!  It’s a bit windy, but this is a good drone.  It can handle it.

Think about where this would take YOU if you did this on a problem that occured in your life.  Think about the space shuttle example, the murder in the city, the hospital where the medical error occurred -- in ALL these cases there were people who did something because of specific THOUGHTS that went through their minds at a particular point in time.

My next question will take me to another place – it will be a major step towards personal growth, because now I will ask myself:  

What thoughts SHOULD have been going through my mind that would have AVOIDED this incident in the first place?

I guarantee that if you ask yourself this question as a result of something that has gone wrong in your life where you, yourself were part of its causes, this question will cause you to STRUGGLE!  Things that go wrong in our lives should always cause us to STRUGGLE.

In the case of my drone, I struggled and struggled and finally realized that I SHOULD have thought:

Although I’ve been waiting since Christmas to fly this drone on the Blue Ridge Parkway, it’s a bit too windy to try it today -- and it’s probably even more windy aloft.  I think I remember reading that we’re not supposed to fly it in high wind conditions, so I’ll wait for a better day.

Now it's time for me to reflect on 1) what I ACTUALLY thought, versus 2) what I SHOULD have thought.

Actual thoughts versus desired thoughts -- actual thoughts versus desired thoughts.  I need to DWELL on this, and then move on to answering…

What is it about the way I am that is evident in these thoughts?

Imagine doing this every time something went wrong in your life!  Imagine what would happen if EVERYONE involved asked these kinds of questions, each time something went wrong -- over and over.

Imagine an organization that launches rockets into space doing this, and the city that is experiencing high murder statistics, or the hospital that is plagued with medical errors.  Imagine your family doing this.

We are a people in crisis -- a crisis of blame and misunderstanding.  No-one is listening to one another.  We all have our own agendas.  

Things that go wrong are the ONLY phenomena of life that are capable of prying each of us out of our own biases -- as long as we're willing to abide by ONE GOLDEN RULE:

Let's all stop blaming other people and things, and instead started looking at ourselves as part of our problems.

About one year ago, my life changed forever...

Before I share the text of this blog, allow me to introduce "Monty Gillard."  Monty is one of Failsafe's Apprentices, rapidly on track to becoming a full-fledged Affiliate.  I hope you take time to read what Monty has to say.  It's more lengthy than our typical blog articles, but I think what he says will resonate within most of you.  Whatever you do, don't miss his final two paragraphs.

  Thanks for sharing this Monty!

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About one year ago, my life changed forever.  As a Contract Field Safety Advisor,  I accepted a new contract with a company who is a client of Failsafe Network, Inc.  I had no prior exposure to Failsafe or Latent Cause Analysis and attended "Day One" of a 3-Day Class with preconceived notions.

This is going to be just another Root Cause Analysis class, with yet another chart to consult in order to get the same results we've always been getting:   it was operator error, or the supervision was insufficient, or the system was flawed, etc. etc. etc.

But to my surprise, this was DIFFERENT.  This was what I always thought learning from things going wrong COULD be.  I realized I had been muzzled by these other, restrictive forms of RCA.

I had become disenfranchised with the Health and Safety Profession as a whole.  I chose this profession because I wanted to make a difference.  However, after being contracted to some of the world’s largest energy companies, I began to realize it is impossible to make a difference when using the investigative techniques used by most of the industry.  Without realizing it, I was contributing to the problem -- especially the blame game. 

It is understandable that when a safety advisor first approaches a work group, their defences will go up.  They do not know whose “side” you are on.   After all, how many times have I heard,

“What does it matter.  If anything goes wrong they are just going to blame me/us anyway."

Safety Advisors are viewed as part of the "management team," i.e.,  “us against them."

This defensive reaction from the groups I was working with offended me at first, and I would try to explain that I was neutral;  that I worked for everybody.  However, as my career progressed, I realized that I did NOT work for everyone!  Most project managers view field safety advisors as their “eyes in the field” and would request audits about the work being done in their areas from a safety perspective.  More often than not, the only concern we would find would be a lack of documentation, or perhaps a small improvement which could be made in safeguarding, or personal protective equipment, etc.  A corrective action item would be created by ME, the safety advisor, and forwarded to the project manager, who then would forward it to the work team.

What is really being accomplished through this process?  It became a circus in many respects.  The safety advisor is viewed as someone who is doling out more jobs for the workers, more paperwork to fill out, or more equipment to buy.  In other words, from the perspective of the people in the field the end result is troublesome.  This perspective does not help with morale in any way.  It is simply someone else coming into an area, looking at a problem,  and deciding what the fix is.  The people who really need to CHANGE - the workers, are not engaged!  

How can this work?

Even more, when an incident occurred, most organizations I was involved with used one of the two most popular Root Cause Analysis templates used in the North American industry.  I found these checklists to be mere crutches, helping people to manipulate the chart until it worked to get you the result you desired.   If the incident was deemed to be a specific worker’s fault, he/she was removed from site or fired.  Problem solved right?  

Every time I heard this happening, and I reiterate EVERY SINGLE TIME, I felt awful, sometimes even sick to my stomach, because I had often known this person and had talked with them.  To make matters worse, I have had Project Managers or Construction Superintendents ask me if “this person should be allowed on site."   The person made a mistake!  They did not do this maliciously or with intent!  This person had almost always co-operated in the investigation and they were always told that “we simply want to learn from this."  Once they were “skidded” from site, what does that do for the morale of the rest of the workforce?  Does this breed trust within an organization?  Or is it another safety document they must review and sign.  Do we really think the workforce is retaining all this information? 

As you can see, my belief in what I was doing was waning, and it was not really the result of any one particular contract.  Often times I would spend long days in camps or hotels and without job satisfaction.  It was difficult to remain focused on my role under such circumstances.

Which brings me all the way back to the beginning.  One week in February 2014 I was exposed to something that would change my professional and personal life forever; the Latent Cause Experience.  How to REALLY learn from things that go wrong in our lives.  I have been fortunate to use LCA in an industrial setting, but I have been more fortunate to also apply its concepts in my home life.  Examining how thing go wrong whether professionally or personally can ONLY be solved by looking at yourself as part of the problem.  There simply is no other way.  

Relationships with people closest to me have actually improved immensely since I learned that you can only learn from the things that go wrong in your life by looking at yourself as part of the problem.

As my personal life changed with LCA, so did my professional life.  The founder of Failsafe Network, Bob Nelms, has given me the opportunity to enter the apprenticeship program towards becoming a Failsafe Affiliate.  This will provide me the avenue to truly make a difference.  Every class offering I have attended or helped present has changed me a little more, not only because I understand the concepts of LCA better, but because of the interactions with the class and how I see myself changing in relating to all of the people in my life.  It has reinvigorated me and I am truly excited about the journey that lies ahead with Latent Cause Analysis. 

I Want to Hurt Them Myself

A dialogue in a recent Latent Cause Experience seminar will have me thinking for a long time.  We were discussing two of the principles of Latent Cause Analysis:  

When something goes wrong, no-one is allowed to blame anyone.  Instead, all involved are required to look at themselves.

I had thought that this principle would encourage the ultimate in personal accountability.  Even the blamers ought to realize that they would get what they wanted -- the people that “did it” would be admitting their own roles.  I learned that this was not good enough for some people.

The second principle is known as the Golden Rule of a Latent Cause Analysis, which states:  We will try to understand why people did what they did to such an extent we’re convinced we’d have done the same thing if we were that person.  

I had thought that this principle would help people put themselves in another person’s shoes before they jumped to quickly into the blaming frame of mind.  I learned that this is also not good enough for some people.

One of the seminar attendees, a manager, objected to these principles saying that he wanted the option to punish someone if he thought it appropriate.  I countered his objection by asking:

If you thought you might have done the same thing if you were the person you wanted to punish, would you still want to punish him?

Yes!  Just because I’d have done the same thing doesn’t make it right!  I thought to myself, “well that’s not a bad point!”

Well then, how would you feel if the person you wanted to punish admitted his error, and even suggested his own “punishment?”

That’s not good enough.  I want to be the one that imposes the punishment.

The discussion digressed into a fictional scenario.  Another seminar attendee said:  Let’s suppose someone did not follow a procedure, and because he omitted a few steps something awful happened and a person actually died.  Let’s also suppose the “culprit” admitted his role.  Even more, let’s suppose the person quit his job, and even walked into a jailhouse and locked himself behind bars for 30 years.  Would this be good enough?

The manager said “no, that’s not good enough.”  I would want to be the one that hurts him for what he did.

I’m not too sure I know what to make of this, but my “gut” doesn’t like it.

What do you think?  What does this say about the human condition?  Are we all like this?  If not, how many are like this?  Even more, what does it say about the hopes of learning from things that go wrong?  So many questions.

Please share your thoughts below!