Showing posts with label incident investigation training. Show all posts
Showing posts with label incident investigation training. Show all posts

Thursday, November 13, 2014

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.

Personal Accountability in Latent Cause Analysis
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!

Tuesday, January 29, 2013

Am I doing something WRONG?

I recently received an email that caused me some dismay.  The email questioned the intent of the 4-day Latent Cause Experience.  Here is the line of the email that bothered me the most:
"Bob, why do you spend so much time teaching people how to do a Maxi-LCA in your 4-day Latent Cause Experience when few if any will ever lead one?”

Ahhhhhhhhh!

The Latent Cause Experience is NOT a class designed to teach people how to do Maxi-LCA’s (although it does teach that).  (Maxi-LCA's are investigations of large, catastrophic events).

It’s also NOT a class designed to teach people how to do Midi’s or Mini’s-LCA's (although it does teach that also).

As a VP from a client-company said, the purpose of the 4-day Latent Cause Experience is to “change the way people think about themselves and their surroundings.”

People ought to walk out of the LCE “seeing things differently,” and according to much of the feedback I receive, they do.  Although this is going to sound awful,

“I could care less about teaching people how to do a Maxi-LCA.” 

I mean that.  It’s like eating.  If the goal is to eat, a person will get fat.  If the goal is to be healthy, a person will most certainly eat and a lot more.  The goal of the LCE is NOT to merely teach people how to investigate catastrophic events.  If that's all you do with your investigative efforts, your company will get fat and DIE. 

The LCE class was designed for a CROSS-SECTION of people in an organization, not just engineers and potential investigators, and the most common comment I receive is:

everyone needs to go through this experience.” 

I’m not saying this to boast, or to try to get more business, but instead to make a point.  The LCE is was designed for EVERYONE.  Many class critiques routinely say "I wish my wife (or husband) went through this class with me," or "I wish I would have experienced this a lot earlier in my life."

The people that understand this, and say "this class is for everyone" are usually the lower-level people -- the people in the field where the "real stuff happens."  The vast majority of these regular folks see the experience as a eureka that opens their eyes to all kinds of things. That’s the intent

Amazingly, the folks that typically are responsible for a company’s investigative efforts usually don’t see this.  They typically think the 4-day class is a Maxi-LCA training class.  Why is this?  Are the people responsible for driving investigative efforts detached from the reality in the field, and too absorbed in the bureaucracy of managing the numbers?

My newest client is a large Canadian firm.  They are “cracking my shell” in the way I see them handling their LCA’s.  Almost all of their LCA’s are being handled as Maxi-LCA’s.  They have stakeholder meetings for all their LCA’s, even for Mini-events.  At this point in their journey, they see little or no value in doing Midi or Mini-LCA’s.  Again, they do Maxi-LCA’s on Mini-Events.  It’s the sharing of evidence that occurs in a stakeholder meeting that they find of so much value, and then answering the question “what is it about the way I am contributed to this mini-event.”  They are passing all the people in their company, from foreman-level up to the President, through the LCE.  They know the LCE is not about doing Maxi-LCA’s on maxi-events. 

The “crudest” culture I’ve ever experienced is at a US-based drilling company.  I struggle every time I go there to work with their people (I have NEVER heard such filthy language).  They have also passed all their folks, foreman and up, through the 4-day class.  They flat-out told me that they need to change their culture, i.e., the way their people see themselves and one another.  That’s the reason they send their folks through the class.  They don’t send foreman to the class so that they can be Maxi-LCA leaders.  They send them to the class to help "change the way they think" about themselves and their surroundings. 

But I am obviously doing something wrong.  Too many people in responsible positions see the Latent Cause Experience as merely a “class to train people on how to lead Maxi-LCA’s.”

What am I doing wrong?