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.

Latent Cause Analysis -- NOT What You Might Think

I wish we would have thought of something different to call our approach to learning from things that go wrong, because Latent Cause Analysis sounds like what one might find when looking for "latent organizational weaknesses," and the two would not be more different.

Let me tell you a short story to help you understand its essence.

A family was eating dinner together. It was Friday evening, and it was part of their tradition to eat ice cream for dessert on Friday’s. The father got up to get the ice cream, and discovered there was not enough left for everyone to eat. The mom said “no worries – if you clean the dishes while I’m gone, I’ll go down to the store and get some more ice cream – I’ll be back in 15 minutes.” So she went to the store and bought the ice cream, and then got back into her car for the short drive home.

She approached an intersection and the traffic light turned red. She stopped the car to wait for the green light. But when she rolled to a stop, the car started idling VERY ROUGH. Two seconds later, it stalled.

She thought “OH NO, NOT AGAIN!” She tried to start it, and it wouldn’t start. She kept cranking the engine. It wouldn’t start. She was the first car at the light when the light turned green, but she couldn’t start the car! There were about 15 cars behind her, waiting to get through the light. They all started getting impatient. Some of them started honking their horns. Others passed her, and were not very happy.

Someone finally helped her push the car to the side of the road and then drove her back home. Of course, by this time, the ice cream melted. Even worse, of course, the mom was obviously distraught. When she finally got home, the whole family was anxious to hear where she had been, and when they heard what had happened they were sorry to hear of her experience. But they were all aware of the PRINCIPLES OF Latent Cause Analysis and jumped right into it as follows:

First, as soon as mom rested a bit and was ready to talk about what had happened, the whole family got together and sat around the table. They talked about the incident and HOW it had happened.

They all heard that the car had STALLED at the traffic light, and then each had remembered that the car had been STALLING for a number of weeks – each time getting a bit harder to start. Everyone remembered smelling GASOLINE when trying to start the car. Although the family couldn’t agree on the CAUSES of the stalling, they certainly could agree that there were some things about THEMSELVES that contributed to the mom’s dilemma.

That, dear reader, is the essence of Latent Cause Analysis -- seeing yourself as part of the problems around you instead of blaming other people and things.

Let me make it perfectly clear that in a Latent Cause Analysis, the first thing that’s usually focused on is the HOW, or the PHYSICS of the event. I’m going to skip that part of the Latent Cause Analysis for the purpose of this article to focus on WHAT’S DIFFERENT about Latent Cause Analysis, and what’s different is TWO QUESTIONS:

The first question this family would answer is "What is it about the way we ARE that contributed to this event," starting with the words “WE TEND TO…… “ and ending with “AND WE KNOW THIS IS NOT GOOD.”

The second question, and the LIFE CHANGING QUESTION, is "What is it about the way I AM that contributed to this event," starting with the words "I TEND TO...." and ending with "AND I KNOW THIS IS NOT GOOD."

Finally, each person would be asked what they intend to do about the way they are – and state their answers in front of everyone.

Imagine doing this in YOUR home! Imagine doing this at work! Don't think it can work?

Try it! The people and organizations that have tried this are flabbergasted at the results. Listen to some of their comments at:

http://www.failsafe-network.com/testimonials

We Are All On A Merry Go Round

I don’t know about you, but I have mixed memories of merry-go-rounds.

I remember my first ride, when my dad took me to the county fair and put me on one of those HUGE horses.  When the MGR started, I totally freaked out.  I cried, I wanted off.  Why did my daddy do that to me?

A year passed.  Time for the next county fair.  When my dad took me to the county fair that NEXT year, he also brought my 2 younger brothers.  Well, guess what we came across.  Yup – the MGR. 

What do you think I did?  Do you think I cried?

Naaaaa.  I wanted to try it again!  After all, my 2 younger brothers were watching and I wanted to look like a BIG BOY in front of them.

So my dad put me on the horse – but this time I was prepared.  I knew what to expect.  It would start going round and round so I braced myself, and YES!  I can handle this!!

But then I noticed the pole I was grabbing.  I never really paid too much attention to it before.  I followed it up to see where it went.  When I looked up, I saw all kinds of crankshaft mechanisms pumping and churning.  Up and down, up and down.  Well the up and down motion of the cranks in combination with the rotation of the MGR made me dizzy.  VERY DIZZY!  I started crying again.  Daddy, daddy, take me off this thing.

How embarrassing.

Next year!

I can’t wait to get back on that stinkin thing.  I got on it, my brothers were watching.  I grabbed the pole.  I intentionally looked up.  YES!  I can do this!  CONQUERED!!!

My dad noticed what I was doing well, so he said to me “well Bobby, since you’re feeling so comfortable maybe you’re ready for THAT!”

And he pointed to this stationary ARM-looking-thing that was off to the side of the MGR.  He said, “now Bobby, if you lean way over you might be able to pull the ring out of the tip of the ARM.  And if you do, you’ll win a free ride!”

Every revolution, I reached more, and more and more.  Finally, YES!  I got the ring.  I almost fell off, but I got the ring!

Human nature.  Fascinating.  Always reaching for more.  Never satisfied with the status quo. 

Isn’t it interesting that hardly anyone rides MGR’s anymore?  What used to be a thrill 50 years ago is NOTHING – absolutely NOTHING today.

What does this mean about ourselves?  Where is all of this leading?  What does it imply about our true willingness to be "safe."  

Just thinking, that’s all.

A Truth Demonstrated by the Domino Analogy

I'd like to discuss one of my favorite analogies – the DOMINO analogy.  Actually, this is MORE than just an analogy.  Analogies are, after all, a COMPARISON between two things to help explain or clarify a thought.  But dominos are MORE than an analogy, or comparison.  They are the ACTUAL THING ITSELF.  Let me explain.

Obviously, if line up all the dominos in a row and then push on the one on the right, EVENTUALLY the one on the left will fall down.  This is “cause and effect” in its most elementary and visible form – and it demonstrates a very important truth.

The interaction between the finger and the domino happened FIRST.  And then the interaction between the rightmost domino and the one next to it happened second, and so on, and so on, until the last domino (on the left) EVENTUALLY falls down.  

Nothing extraordinary here, right?  Well hang in there and I’ll make my point.

In the “Root Cause Analysis” world, we always start with the LAST domino – the one on the left.  It’s the event we’re investigating.  Initially, we cannot SEE the dominos on the right, but we know they are there.  Investigations uncover them, one at a time, discovering the important cause and effect relationships.

But here’s the point I’d like to make.

As the cloak is pulled back, and we reveal more and more dominos, we’re actually GOING BACK IN TIME.  Remember, the domino on the RIGHT has to fall BEFORE the dominos on the LEFT fall down.  The cause of the cause of the cause of the cause relationships reveal that NOTHING HAPPENS in our lives without causes that originated in the past.  This is ALWAYS TRUE.

Let’s say I did something that caused a major problem, and you want to know why I behaved in that manner.  Do you think you’d be able to trace some of the causes of my behavior back to my parents?  Probably.  So let’s go to my parents.  Why did they raise me the way they raised me?  Do you think you’d be able to trace some of the causes of THEIR behavior back to THEIR parents?  SURE!

The dominos are interesting because they suggest that that we (as humans) might not be responsible for ANYTHING that has happened in the PRESENT. 

Everything that happens today was really caused by people that came before us.

Now, of course, there’s a LOT MORE TO THINGS THAT GO WRONG than that.  We ARE a lot more responsible than it seems.  And I’ll certainly be talking about them in future blogs.

For now, please realize that...

..whatever you do today, and how ever you are at present is affecting the future in ways you cannot even remotely conceive.

Isn’t all this fascinating?

Thoughts About September 11, 2001

September 11, 2001 was obviously a day that most of the world will never forget.

I grew up in New Jersey and spent a lot of time in NYC.  My father worked there.  My brother still works there.  I’ve eaten with my family on top of the world trade center in the Windows of the World restaurant.

On September 11, 2001, however, I had already moved into our mountain house in Virginia.  When I heard what was happening in my beloved city, I was glued to the TV like almost everything else.

My initial horror turned into relief as I heard that the NYC fire department was at the scene.  I thought everything would be okay – after all, they’re the best in the world at what they do.

Then the unthinkable happened.  The first tower collapsed.  And then the second.

How can any human being witness what unfolded that day without something profound occurring within them?  

At least, that was my initial emotional response.

But then an email made me realize the status of our society.  I received the noted email 30 minutes after the 2nd tower collapsed, and it  shook me to my core.  I’ll read what it said:

“Do not let terrorism, which is designed to create fear and stop production, halt your life or work.  Stay focused and do not stop what you’re doing.  May God help us all and the decisions we must make.”

I remember thinking “I’m supposed to stay focused?  On What?  I’m not supposed to "stop production?"  I’m simply supposed to keep working and not let this bother me?  I’m not supposed to grieve, wonder, pray – I’m supposed to simply keep doing I’m doing?  What kinds of calloused people have we become? 

What level of event will it take to get us to stop and listen and learn?  

Please try to relate this to where you work, where you live, and even your families.  And please try to consider this:

Failure is the only phenomena of life capable of getting our attention when we’re too busy doing something else.  Nothing else is able to tear us away from the grasp of our own objectives, desires, and goals to force us to look at what we’d rather not look at.

Do you know what “failure” is?  Do you treat it as an ugly, nasty inconvenience?  If so, I’m afraid you are on the road to 911 experiences in your lives.  Because if we don’t learn from the smaller failures of life, those smaller failures are going to turn into larger ones.  Larger and larger and larger until we eventually listen.  Eventually, we’ll all learn what we need to learn.  The only choice we have, it seems, is when.

Let’s learn from the small problems in our lives so we don’t have to experience the catastrophic ones.

Failure is not what we think it is.

The Pickle Juice Analogy

A few years ago I was working with an affiliate whose name was Rob Statham (www.goosebear.com).  Rob is a master at creating analogies.  My favorite of his is one about pickle juice.

He said something like:

People are like cucumbers who have been immersed in pickle juice.  No matter where a person lives, no matter what that person does, s/he is being influenced by the pickle juice.  It’s not their “fault,” in fact they have no choice.  It’s there and they are immersed in it.

It’s interesting what happens when something goes wrong.  We find the former cucumber, pull it out of the pickle juice, and then complain that the cucumber has turned into a pickle.  How dare you are a pickle!  We hired a cucumber.  You’re fired!

Most distressingly, what most companies do is look for a new cucumber to insert into that same pickle juice. 

Insanity!

The pickle juice is, of course, the culture – a way of life of a group of people – the attitudes, beliefs, values, and assumptions that they accept, generally without thinking about them, and that are passed on by communication and imitation from one generation to the next.

When things go wrong, let’s focus more on the pickle juice and less on the cucumbers.

First Video-Blog: Root Cause Analysis for Culture Change

Welcome to my FIRST Video-Blog (VBLOG)!

I will be doing my best to produce one of these VBLOGS per week.  I'll do my best to keep each one about 3 to 4 minutes in duration.  You can either look at the video, or simply read the text in this blog article.

Please let me know what you think!

Some say that culture has nothing to do with things that go wrong.  We say that is has everything to do with it.  The way we are is the cause of all that goes right and all that goes wrong.

Hello this is Bob Nelms and I’d like to talk a minute or two about culture.

Culture:  a way of life of a group of people – the attitudes, beliefs, values, and assumptions that they accept, generally without thinking about them, and that are passed on by communication and imitation from one generation to the next.

I wonder if we can trace the causes of any and even all of our problems back to culture?

That’s the same thing as wondering if we can trace the causes of any and all of our problems back to our attitudes, beliefs and assumptions.

Let me ask you this. 

What if part of the causes of the image you’re seeing was a faulty high level alarm on vessel?  What if people know about that faulty high-level alarm, but didn’t do anything about it? 

I wonder why they didn’t do anything about it?  Do you think we could trace the reasons why back to their attitudes, beliefs, values, and assumptions?

If so, that’s culture.

As a person who’s been dealing with things that go wrong since 1974, I can categorically tell you that CULTURE is responsible for all that goes right and all that goes wrong. 

But I wouldn’t want to leave this discussion without pointing out something else.

Culture is people!

You can’t talk about culture without talking about people.

Everything that goes right and everything that goes wrong can be traced back to people – their attitudes, beliefs and assumptions.

Use yourself as a test-bed and you’ll see what I mean!

When something goes wrong in your life, ask yourself “what is it about my attitudes, beliefs, or assumptions” that contributed to this event? 

I don’t know about you, but I can ALWAYS find something about myself that contributes to my problems – ALWAYS.  Even more, I can ALWAYS seem to acknowledge that it’s something about the WAY I AM that is a bit problematic. 

The point is that together with everyone else around me, the way we ARE is CULTURE.

We are in the Root Cause Analysis business, which means we are in the Culture-Change business, because if CULTURE doesn’t change, nothing else will change.

See you next week.

Why Do Problems Exist, Part 3

Why Do Problems Exist -- Conclusions

Part 3 of a 3 part series exploring philosophical and religious thought about why problems exist.

In the first article of this series, I explored what the great Western thinkers have written about "the causes of things in general."  In the second article, I explored what these thinkers have said about "things that go wrong, in particular." 

In reviewing those last two articles, I became frustrated with myself for what I had written.  It seems I was in a questioning mood, and wondered aloud about much of what I had read from these great scholars.

Therefore, in this final article I will 

not be wondering anymore.  I will combine the results of the first two articles to draw my own conclusions about the problems of life.  You, the reader, might come to different conclusions.

The causes of everything we sense, including all of life's phenomena, can be broken into the following categories:

Purpose:  There is a purpose to everything we can see.  This is most obvious in our human creations, where we can consider a desk, for example, and know that its creator had a purpose in mind.  But I have concluded that all of nature also has a purpose.  There's a purpose for ourselves, trees, the air we breath, the bacteria and other microbes that float around and all that we have not even discovered.  There's also a purpose for the pain we feel when things go wrong in our lives.  All of life has purpose.  There is no exception.

Substance:  There is a substance involved in all we can see.  Without substance, nothing would exist.  A desk, for example, might be made of wood -- perhaps an oak tree.  When we consider why something exists, we have to acknowledge that its substance is part of its causes.  But again, the same is true of all of nature.  We, as humans, are made-up of substances, as are the trees, the air, and even bacteria and other microbes.  Even the pain we feel when things go wrong in our lives has a substantive element.  Chemicals are produced within our bodies that are deciphered by our brains as pain.

Pattern:  There is a plan, or template used in all that we can see.  This plan is not the same as "purpose."  The purpose of a desk might be to provide a work surface for writing.  The plan for creating the desk would be the templates used in cutting the wood to make the desk.  Without this pattern (plan), the desk would not exist.  The same is true for ourselves, as well as the trees we can see, as well as the air, bacteria and other microbes -- none of these things would exist if it were not for the "pattern" used to create these things.  This means that there is also a "plan" that exists for how emotional pain comes into our lives.  There is always a plan.  There are no exceptions.

Energy:  There is a source of energy that exists behind all we can see.  Energy was needed to create the desk from an oak tree, according to a plan, and suited for a purpose.  The same is true for ourselves, as well as trees, bacteria, and all that exists.  Nothing would exist the exertion of energy.  Even the pain in our lives does not come free.  The pain comes from the exertion of energy on a substance according to plan with a specific purpose.

I don't know about you, but I am awed at these conclusions.  Everything in existence has meaning!  All of life's phenomena have purpose.  

Nothing happens, anywhere, to anything or anyone without a predefined purpose and plan!