The Executive Staff at our site mandated the use of the Mini and Midi-RCA. We have Midi-RCA's in progress. The technique helps us look at latent defects.

I agree that setting expectations up-front is a good thing. I require it for the students in my 4 hour classes by expecting a Midi-RCA before they get credit for the class. I tell them this up front. I also have a multiple choice, open book test that we grade together at the end of my course to ensure the important points hit home.

I didn't go to the training, but your message INSPIRES me! Really, I just walked into my office after spending two days on a breakdown where I've been pulling my hair out from trying to answer to "why, how, and WHEN" and there is your newsletter. You are right on the money. I had the Kepner Tregoe ATS training a few years ago and I still use it, and recommend it, and wish that more people would use it in our organization... BUT WISHING AIN'T GOING TO MAKE IT HAPPEN. You made a bold statement and I liked it, I needed it, and I'm going to do something about it!

The training I received has completely enhanced our ability to get folks at the line supervision level to understand incident probability and that latency is not system failure but an inherent characterisitc or decision of an individual.

A reporter once asked President Harry Truman why people called him "Give-em Hell, Harry." He replied that he did not give people Hell. He just told them the truth and it felt like Hell. Telling people the truth can be a tricky business and the reaction you can get may be part of the reason folks go back to something familiar.

It's not your training sessions, it's the people in them. They are taking a new tool back to sites that are not prepared to receive them. We need to educate our leadership and prepare them for accepting the findings of the RCA approach. We had a site recognize that the other investigative methodolgy they were using does not get to the Latent Causes. They asked us to come in and do an RCA the way you teach it. After we did, and after we pointed out some true latent causes, they went into denial and did not change a thing, even though that's what they said they wanted! Don't give up! We have a lot of work to do on our end. Hang in there, you're doing good things!

My guess is people fall back into their own investigative habits because they are pressed for time and a FIX!!! With all of the large capital projects that we have in the field I continue to see personnel being disciplined just because of a probabilistic outcome of an injury, when the same latent causes show up on a similar incidnet but with no injury. All I can say is hang in there. Out of all the seeds you plant, some are taking.

Latent causes are management, systems, and people issues that are difficult to deal with, are not prone to quick fixes, and very few people have the training they need to deal with these systemic, long-term issues. Our normal management and engineering training do not prepare us for dealing with these types of soft issues. We are approaching the days where we need industrial psychologists and NFL gootball coaches on staff.

If management buys into these 7 Expectations without participating in the training, I'd be surprised. If they cannot attend the full training, urge them to attend a preliminary overview session of one, two, or four hours (their choice). It could even be the first hour of the "Experience."

I'd take the 6 questions and boil them down to 3 or 4 provocations, then simply ask the questions in class and record the responses from the students. This would become the summary for plant management. No names should be tied to any specific responses.

Expectations are at the core (as you say) but need to be underpinned by something else. Most of the 7 Expectations are action based -- exactly what you and plant leadership teams want. But SAYING that things are required is easy. People will only become engaged, truly engaged, when they sense integrity. If people sense that management actually sees value in RCA, they will become engaged. But your 7 Expectations are more a reflection of what YOU value than what management values. I would like to see the beliefs and principals articulated by the mangement teams themselves, rather than you.

Please take a look at what I've done after pondering everyone's responses. I've renamed the document as "Expectations." The link includes a Word Document with 4 pages:

• Cover letter to the person that schedules Root Cause Analysis Training
• Provocative Thoughts about Root Cause Analysis
• Expectations of Management Prior to the Training
• Management's Expectations of Attendees (seed document)