Latent Cause Analysis (LCA) Reporting Template

TEST -- for comment only
Please review this template, and then go to the last page (Summary and Reflection) and click the link to share your thoughts.  Note:  Any data that you input will NOT be processed by this forum until  it is activated after this test.
Explanation
Brief Description of Latent Cause Analysis Process
Event Description
Evidence Summaries
Physical Causes and Remedial Actions
Human Causes, Latent Causes and Suggested Remedial Actions
Summary and Reflection
Failsafe Network, Inc.    PO Box 119 Montebello, VA 24464   www.failsafe-network.com   bob@failsafe-network.com   540-377-2010

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Explanation

A Latent Cause Analysis is a way to help people see themselves as part of their problems, as opposed to blaming other people and things.  The Latent Cause Analysis process requires the "right" people to ask “what is it about the way we are that contributed to this problem, and what are we willing to do about it” and “what is it about the way I am that contributed to this problem, and what am I willing to do about it?" Latent Cause Analyses ask a person to be introspective about themselves and their surroundings.

Imagine a world where everyone looked at themselves rather than pointing fingers at others.

First we need to see ourselves as part of the problem, then we’ll be ready to change.

One of the most frustrating findings of formal Latent Cause Analyses is that many of the underlying causes of major incidents are known AHEAD OF TIME. Warning signs almost always precede major incidents, but are neglected. Frustrating equipment, people, and systems are usually recognized, but often ignored until they result in disaster.

It is people that ignore and neglect these problems. In the limit, people cause problemsALL people. We either do things we should not have done, or neglect to do things we should have done. Although most people easily see these qualities in other people, it is rare to find individuals who can see their own role in things that go wrong.

A Latent Cause Analysis is an attempt to help people see themselves as part of their problems.

The ultimate intent of the Latent Cause Analysis is not to generate action items or recommendations. Instead, the ultimate intent of a Latent Cause Analysis is to change people, because:

When people change, everything else will change.

A Latent Cause Analysis is primarily, therefore, a self awareness exercise. If we look for our own role in things that go wrong often-enough, healthy people will “connect the dots” and desire a change.

But a Latent Cause Analysis is also an organizational awareness tool. In this respect, when you finish your Latent Cause Analysis, please complete and SUBMIT this form.  It will be automatically sent to your area Mother-Source who is responsible for identifying and acting on COMMON LATENT THREADS.

TOP     Brief Description of Latent Cause Analysis Process

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Brief Description of Latent Cause Analysis Process

The purpose of this template is to guide you, step-by-step, through the reporting of the most significant conclusions of your LCA for eventual tracking and trending purposes.  You will be asked to report on the Physical Causes of the event, as well as the 3 most significant Human Causes and their associated Latent Causes.  It is expected that you have followed each of the following evidence gathering steps prior to reporting these conclusions.  Wallet Cards and a GoPage are available on www.failsafe-network.com that complement the following Process DescriptionLinks are provided throughout this template to aid with definitions.  When you are finished, click SUBMIT at the end of the template and your results to be added to our Database.  A MS WORD reporting template has been created to extract this information in a standardized report-format.

Brief Process Description:
Begin by acquiring the "5 Items:"
   - Statement:  state who, what, where, and when the event occurred
   - Schematic:  a sketch of the component of system involved in the event.
   - Relationship:  another sketch showing the relationship of the component or system above to the bigger picture
   - Sequence:  a brief (approximately 5 bullets) sequence of events
   - Oddities:  aside from the event itself, was there anything else odd?
Develop a WHY QUESTION:  What question will you answer in this LCA?  This WHY Question should be related to the "what" in the above "statement."
List the evidence to gather:
   - People:  Who should I (we) talk to?
   - Physical:  What physical evidence should I (we) gather?
   - Paper: What paper evidence should I (we) gather?
Gather the evidence.
Summarize the evidence.

Once you have done the above, you are ready to proceed with this template.

TOP     NEXT (Event Description)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Event Description

Are you reporting a Maxi, Midi, or Mini-LCA?

What event have you investigated?  Please state the actual or potential consequences you have investigated?  This should relate to the "what" in the above "Statement."

Where did this event occur?

When did this event occur?

Who did this event happen to?

WHY Question: What question have you answered in this LCA?

Summary Sequence of Events (approximately 5 bullet items)

Submitter's Last Name:

Submitter's First Name:
Submitter's Company:
Completion Date:
TOP    PRIOR (Brief Description of LCA Process)    NEXT (Evidence Summaries)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evidence Summaries

NOTE:  For each of the following, be as specific as possibleOthers will judge your conclusions based on the details you provide.

What did you learn from the PHYSICAL Evidence (What said what)?

What emerging symptoms or warning signs portended this event? (as revealed by the Physical Evidence)?

What did you learn from the PEOPLE Evidence (Who said what)?

What emerging symptoms or warning signs portended this event (as revealed by the People Evidence)?

What did you learn from the PAPER Evidence (What said what)?

What emerging symptoms or warning signs portended this event (as revealed by the Paper Evidence)?

TOP    PRIOR (Event Description)    NEXT (Physical Causes and Remedial Actions)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Causes and Remedial Actions

Physical Causes:  Based on all the evidence, HOW did the event occur?  (What were the PHYSICS of the event?)  BE SPECIFIC.  Do not mention anything about people.  Use sentences and paragraphs so that the reader can understand your conclusions.  Write in past tense.
Reactive Actions Taken.  What has already been done in response to this event?
SMART Preventative Actions Recommended.  What else should be done to make sure the Physical Causes cannot recur? 

SMART Actions are:  Specific, Measurable, Actionable, Reasonable, and Time-Bound

TOP     PRIOR (Event Description)     NEXT (Human and Latent Causes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please report on the 3 most significant Human Causes of this event -- one Human Cause at a time.

Human Cause # 1     and its Latent Causes and Suggested Remedial Actions

ACTUAL Behavior (Human Cause #1)

DESIRED Behavior

Who did what wrong?  A point of inappropriate human intervention.  Past tense and very specific.  Do not mention thoughts or attitudes

In retrospect, what should the person have done?

Triggering Situation

When did the person do what they did?  Alternatively, when should the person have behaved differently?  Begin with the word "When........."

ACTUAL Thoughts

DESIRED Thoughts

What ACTUAL thoughts went through the person's mind at the above point in time?

What thoughts SHOULD have gone through the person's mind to have produced the DESIRED behavior?

Organizational Latent Causes (OLC's) and Suggestive SMART Actions (SA's)
Answer:  What is it about the way WE are that is evident in the above thoughts?  Must be generic (not specific to only this event), and written in PRESENT TENSE.  List up to 3 of the most significant Organizational Latent Causes, and then any SMART Actions that would address these Latent Causes (if possible).
OLC1 SA1
OLC2 SA2
OLC3 SA3

REMINDER:  SMART Actions are:  Specific, Measurable, Actionable, Reasonable, and Time-Bound

Personal Latent Causes (PLC's) and Suggestive SMART Actions (SA's)

NOTE:  Only report Personal Latent Causes for Mini-LCA's  NOTE

Answer:  What is it about the way I AM that contributed to this event?  Must be generic (not specific to only this event), and written in PRESENT TENSE.  List up to 3 of the most significant Personal Latent Causes, and then any SMART Actions that would address these Latent Causes (if possible).
PLC1 SA1
PLC2 SA2
PLC3 SA3

REMINDER:  SMART Actions are:  Specific, Measurable, Actionable, Reasonable, and Time-Bound

TOP     PRIOR (Physical Causes)   NEXT (Human Cause #2 if necessary)

SUMMARIZE and REFLECT (if no more Human Causes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please report on the 3 most significant Human Causes of this event -- one Human Cause at a time.

Human Cause # 2     and its Latent Causes and Suggested Remedial Actions

ACTUAL Behavior (Human Cause #2)

DESIRED Behavior

Who did what wrong?  A point of inappropriate human intervention.  Past tense and very specific.  Do not mention thoughts or attitudes

In retrospect, what should the person have done?

Triggering Situation

When did the person do what they did?  Alternatively, when should the person have behaved differently?  Begin with the word "When........."

ACTUAL Thoughts

DESIRED Thoughts

What ACTUAL thoughts went through the person's mind at the above point in time?

What thoughts SHOULD have gone through the person's mind to have produced the DESIRED behavior?

Organizational Latent Causes (OLC's) and Suggestive SMART Actions (SA's)
Answer:  What is it about the way WE are that is evident in the above thoughts?  Must be generic (not specific to only this event), and written in PRESENT TENSE.  List up to 3 of the most significant Organizational Latent Causes, and then any SMART Actions that would address these Latent Causes (if possible).
OLC1 SA1
OLC2 SA2
OLC3 SA3

REMINDER:  SMART Actions are:  Specific, Measurable, Actionable, Reasonable, and Time-Bound

Personal Latent Causes (PLC's) and Suggestive SMART Actions (SA's)

NOTE:  Only report Personal Latent Causes for Mini-LCA's  NOTE

Answer:  What is it about the way I AM that contributed to this event?  Must be generic (not specific to only this event), and written in PRESENT TENSE.  List up to 3 of the most significant Personal Latent Causes, and then any SMART Actions that would address these Latent Causes (if possible).
PLC1 SA1
PLC2 SA2
PLC3 SA3

REMINDER:  SMART Actions are:  Specific, Measurable, Actionable, Reasonable, and Time-Bound

TOP     PRIOR (Human Cause #1)   NEXT (Human Cause #3 if necessary)

SUMMARIZE and REFLECT (if no more Human Causes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please report on the 3 most significant Human Causes of this event -- one Human Cause at a time.

Human Cause # 3     and its Latent Causes and Suggested Remedial Actions

ACTUAL Behavior (Human Cause #3)

DESIRED Behavior

Who did what wrong?  A point of inappropriate human intervention.  Past tense and very specific.  Do not mention thoughts or attitudes

In retrospect, what should the person have done?

Triggering Situation

When did the person do what they did?  Alternatively, when should the person have behaved differently?  Begin with the word "When........."

ACTUAL Thoughts

DESIRED Thoughts

What ACTUAL thoughts went through the person's mind at the above point in time?

What thoughts SHOULD have gone through the person's mind to have produced the DESIRED behavior?

Organizational Latent Causes (OLC's) and Suggestive SMART Actions (SA's)
Answer:  What is it about the way WE are that is evident in the above thoughts?  Must be generic (not specific to only this event), and written in PRESENT TENSE.  List up to 3 of the most significant Organizational Latent Causes, and then any SMART Actions that would address these Latent Causes (if possible).
OLC1 SA1
OLC2 SA2
OLC3 SA3

REMINDER:  SMART Actions are:  Specific, Measurable, Actionable, Reasonable, and Time-Bound

Personal Latent Causes (PLC's) and Suggestive SMART Actions (SA's)

NOTE:  Only report Personal Latent Causes for Mini-LCA's  NOTE

Answer:  What is it about the way I AM that contributed to this event?  Must be generic (not specific to only this event), and written in PRESENT TENSE.  List up to 3 of the most significant Personal Latent Causes, and then any SMART Actions that would address these Latent Causes (if possible).
PLC1 SA1
PLC2 SA2
PLC3 SA3

REMINDER:  SMART Actions are:  Specific, Measurable, Actionable, Reasonable, and Time-Bound

TOP     PRIOR (Human Cause #2)  

SUMMARIZE and REFLECT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reflection

What is your OWN, PERSONAL bottom-line learning from this event?  (team-based if maxi or midi)
What do you think OTHERS should learn from this event?
Summarize emerging symptoms (or warning signs) that portended this event.
While investigating this event, what did you discover that was good, or positive (instead of bad, or negative)?

Thank You for Taking the Time to SHARE what you Learned!

TOP  

Click TOP to go back and modify any parts of this report. 

Do not click SUBMIT until you are finished with this report.

Explanation:  The SUBMIT button has been deactivated on this web-based TEST form.  When this forum is made live and active, results are automatically inserted into a web-based spreadsheet when the user clicks on SUBMIT.  This spreadsheet can subsequently be accessed for standard reporting and analysis. 

Please let me know what you think about this web-based template.