The issues of blame, discipline, fear, punishment, and accountability are near the root of why we don't learn more from things that go wrong.  There is most certainly a need for rules, regulations, policies, and procedures in our businesses.  Likewise, there is most certainly a need to enforce them by applying discipline to those who do not abide.  However, it is vitally important to acknowledge the reason for our rules (etc);  they exist to help PREVENT incidents.  The time for discipline is BEFORE an incident, not after one. 

Unfortunately, most organizations have it backwards.  They do not apply their disciplinary policies in a consistent manner ahead of time.  Instead, they wait for something awful to happen and then go after the person.  This is outrageous, illogical, and immoral.  Instead of disciplining people involved in an incident, Failsafe STRONGLY encourages the following policy:

The management of this organization promises that no-one will be disciplined as a result of this LCA unless they have broken a criminal law.  In return, the management of this organization expects all involved parties to participate in the LCA as requested to make sure we learn as much as possible.

The Combing Process is an FMEA-based (Failure Modes and Effects Analysis) tool for identifying your "significant few" chronic failures RAPIDLY (hours or days).  It is NOT the tedious and time-consuming "hazards analysis" tool many are familiar with, but a means of identifying ACTUAL failures occurring in an EXISTING operating environment.  It is an approach which goes to the hands-on operating and maintenance people for information, rather than on relying on existing data-bases.  It is based on the concept of the "invisible plant," which is known only by the people and NOT by the data.  It fits right into Failsafe's overall philosophy for Latent Cause Analysis, which focuses on shock and surprise (discovery) to help make the case for change.

Nothing in our existence happens without it being known in one form or another.  Evidence is the word we use to describe how we become aware of something.  More specifically, evidence is "the way an event or condition manifests itself."  Evidence contains "everything we need to know" about an undesired event.  In fact, evidence includes everything we need to know about life itself.  Without evidence, an RCA is impossible because RCA's, by definition, are evidence-driven endeavors.  Note:  Without evidence, one can hypothesize, theorize, speculate, and agree on the causes of an event.  However, such endeavors should not be called Latent Cause Analyses!  RCA's must be EVIDENCE-DRIVEN.

"When something goes wrong, we will all try to understand why each person (at all levels) did what they did to such an extent we're convinced we would have done the same thing." 

Human beings are responsible for everything that goes wrong (and, of course, everything that goes right).  Any attempt to sidestep this truth is, in itself, a major cause of our problems.  When we do RCA's,  we need to acknowledge how we intervened (interacted with the physical world) to cause a problem.  Therefore, Human Causes answer the question:  Who did what wrong?  Human Causes are written in bullet-form, in past tense, are very specific, and are always tactical in nature (specific acts of commission or omission).  They are the "sharpest end" of human intervention with the physical system.

It's unresolved small problems that cause our big problems.  We should have learned this by now.  Whereas most organizations seem content to wait for something big to go wrong, then pounce on it with a rigorous investigation, it would be much more effective to act on small problems BEFORE they cause the large one.  Inculcation is word used to describe the effort to involve everyone in addressing the small problems in their lives.  It acknowledges a need to ingrain a root cause mentality throughout the workforce, "drip-by-drip," involving more and more people, eventually pervading the organization.  It focuses on people's attitudes towards "small problems."  It focuses on changing people's minds about "why things go wrong."

Imagine being born, growing-up, and living your whole life on a Merry-Go-Round.  The spinning, whirling motion would affect everything you did, every day of your life.  This concealed, hidden, veiled, but ACTIVE, POTENT, and MATURE force in our lives distracts us from doing what we OUGHT to be doing.  It is "the way I am," or "the way we are," and "the way things have always been."  Latency is the primary target of Failsafe's approach to Latent (Root) Cause Analysis because it is the most effective thing  we can control.

Latent Causes are spoken admissions made by the people that contributed to the incident and answer the question:  "What is it about the way I am that contributed to this incident?"  Latent Causes are written in present tense (this helps point-out that they are still causing problems), generic, and as seen through the involved person's eyes after having experienced the evidence.

LCA

Latent Cause Analysis is most understood in contrast to "Root Cause Analysis."  Root Cause Analysis is a misnomer.  No-one does it, and yet everyone says they do it.  Root Cause Analyses that do not point to "Adam and Eve," or "The Big Bang," or "The Beginning of Time" are NOT Root Cause Analyses.  Latent Cause Analysis is a more truthful, appropriate, and effective endeavor that helps everyone see themselves as part of the problem instead of blaming equipment, other people, or even systems.  Latent Cause Analysis is Failsafe's version of Root Cause Analysis.

Midi-RCA's are performed on Midi-Events.  They are lead by an insider (someone from the affected site but as detached as possible from the specific event), always involve at least 3 additional  evidence-gatherers, always involve the stakeholders, and always define Physical, Human, and Latent Causes.  Midi-RCA's ought to be performed about 4 times per 100 people per year. Midi-RCA triggers ought to be set accordingly.

Mini-RCA's are performed on Mini (or normal) events.  They are performed by one person, a few people, or larger group of people -- whoever comes in contact with the event.  They do NOT involve additional, detached evidence-gatherers, nor any additional stakeholder meeting -- the stakeholders are often involved throughout the whole process.  Mini-RCA's always define Physical, Human, and Latent Causes.  Everyone in the organization ought to be involved in 4 Mini-RCA's per year, analyzing any problem that is not a Maxi or Midi-Event.

The Mother-Source is the nurturing entity that helps people inculcate a latent cause mentality throughout an organization.  It is a caring group of people that has banded together to make invisible issues visible.  The creation of a Mother-Source is the single most important step towards changing an organizational culture in a positive direction.  It is typically a group of 5 or so individuals that feel the responsibility of making "latent cause thinking" a part of an organization.

Mother-Source-Central (MSC) is a licensed network of Mother-Source resources from all over the world to help any organization inculcate a latent cause mentality at their site.  It is comprised of people who are available to investigate your incidents, help train you on how to investigate, lead the RCA effort at your site, or support it in any manner you wish.

Operation Failsafe is an evolving and comprehensive plan for ingraining the latent cause mentality within people and their organizations.  Dependent on the formation of a "Mother-Source," it is a bold, aggressive pursuit into the causes of an organization's failures with an end-objective in mind:  people who DESIRE to know and act on the truth behind why things go wrong.

As time marches-on, history accumulates.  Paper Evidence is usually relegated to "whatever has been WRITTEN" about our history.  It usually includes maintenance, training, operational, and similar data.  It can written on paper (thus PAPER evidence), or stored digitally, or even available on the internet.  Paper Evidence is one of the three key forms of evidence.

When something goes wrong, people know about it through their senses.  They absorb the event as if they were a sponge absorbing water.  People Evidence is "whatever has been absorbed."  It resides within the human mind.  It contains historical as well as interpersonal information.  It is the most important of the three key forms of evidence.  Although people usually know EVERYTHING about "why things go wrong," they will often not share what they know because of fear and other negative emotional factors.

Physical Causes explain the PHYSICS of an event or condition.  Physical Causes are written in paragraph-form, are always "past-tense," and must be stated in as specific a way as possible. 

Physical Evidence focuses on "the way it ended-up."  Physical Evidence can usually be divided into 2 facets:  positional evidence and parts evidence.  Positional Evidence captures WHERE things are.  Parts Evidence characterizes the CONDITION of each piece.  Although engineers usually think this is the most important form of evidence, it usually yields little about the LATENT causes of an event or condition.

The Principal Investigator (PI) is the person who leads a Latent Cause Analysis.  This person should be ignorant of the problem being investigated (including ignorant of the equipment, people, culture, systems, and everything surrounding the event), experienced in Latent Cause Analysis, and available to work on the LCA full-time until it is completed.  More importantly, this person ought to have a PASSION for revealing truth, and COMPASSION for people.

ROOTS is the acronym that defines Failsafe's investigative method.  It is a flexible, open-ended, practical approach which helps the inquirer DISCOVER  the physical, human, then latent causes of failure.  It is NOT a form-driven, pick-list-based, computerized, software package with "canned" questions or other "boxed-in" ways of doing things.  Rather, it is a means of intentionally driving the serious inquirer into areas  most in need of clarification. -- a totally EVIDENCE-driven process.

• Respond by Freezing the Evidence

• Organize a team of Stakeholders

• Order your Conclusions with a WHY Tree

• Translate your Findings so that Others can understand

• Sustain your efforts by reporting back to the Mother-Source

RCA

Root Cause Analysis is "whatever you want it to be," because it depends on what you are willing to see.  Root Cause Analysis is no longer being taught by Failsafe, because Failsafe has deemed it an overused, little-understood, and inappropriately applied phrase.  Beware of those who say they do "Root Cause Analysis."  Question them.  Ask them what they mean by "root cause."  If you do, you'll see the problem.

A latent cause mentality is a growing, deepening thirst within an individual to understand why things go wrong.  It is not a tool, but a way of thinking that focuses on understanding rather than blame.  In the limit it is an introspective journey focusing on ones-self instead of other people and other things.

The Root Cause Conference is a Yahoo-group email-based forum developed and moderated by C. Robert Nelms.  It is a non-proprietary, inter-company, inter-industry body of people from all over the world who are interested in root cause analysis.  Many of Failsafe's competitors are active on this forum, making it rich in ideas and debate. 

The cause of the cause of the cause of the cause....  Please ask yourself where this questioning would take you.  True Root Cause Analyses will force you to look beyond your own organization, and into things like local culture, family situations, and national mindsets.  But each of these things are, in turn, also caused by something.  It is an undeniable fact of life that things today are caused by things that happened "yesterday."  Since each layer happened PRIOR TO the one before, the Root Cause of all our problems must be at the beginning of time.  Think about it.

Similar (but different) than ABC analysis (antecedent, behavior, consequence), the SFO technique is a practical and decisive way to help put yourself in someone else's shoes -- to understand why people do what they do.  The SFO technique is a rebuttal to those who insist that we must be psychologists to understand our fellow human-beings.  The SFO technique is a way to surface the LATENT causes of a failure in way which is bound to cause change.  The SFO technique is guaranteed to make you a more UNDERSTANDING individual because if replaces BLAME with UNDERSTANDING so that REAL CHANGE can occur.

A stakeholder (with respect to root cause analysis) is anyone whose behavior has to change as a result of something that has gone wrong.  Stakeholders are identified after evidence is gathered and causes become apparent to the evidence-gatherers.  Stakeholders can be from any level of the of the organization and typically include a cross section ranging from hands-on to executive levels.

After evidence is gathered by outside, non-partial people, stakeholders are identified and asked to attend a meeting.  During this meeting, summarized evidence is presented to the stakeholders.  After adjourning for one night to think about the evidence, the meeting is reconvened so that the STAKEHOLDERS THEMSELVES can define the Physical, Human, and Latent Causes (as well as any action items).

People

Physical

Paper

Bias is the enemy of Root Cause Analysis.  Most of the time, bias is not even intentional --  it's part of being human.  Each of us has our own life experiences that taint our vision of truth.  Therefore, when a Maxi or Midi event occurs, it is important to do "whatever it takes" to assure that the truth is revealed.  A very effective way of doing this is to take advantage of the notion of the 3Ps.  The Vector Approach to Evidence-Gathering uses 3 separate people to lead the evidence gathering -- one for each of the 3 Ps.  Most importantly, these 3 people are kept separate -- they are not allowed to talk or share information, until the Principal Investigator is ready to bring them all together.  This helps to assure that people are not pulled immediately down the wrong path without considering all the evidence.

A WHY Tree is not a Fault Tree, although it looks like one.  It is not a logic tree (because logic trees are used to guide people through KNOWN solutions to a problem).  It is not a fishbone (because fishbones have pre-determined "bones").  Rather, WHY Tree is a means of documenting where you are in your current understanding of a problem, whether it be with a team or as an individual.  It is also a technique for keeping investigative teams on-track.  Most importantly, it is a way of showing others what you have discovered in your RCA.

CAUTION:  Constructing a WHY TREE is NOT the same as doing a Root Cause Analysis!!!  A WHY Tree is NOT an answer-generating machine.  The answers are in the evidence, not in the WHY Tree.  WHY Tree are usually not even mentioned during the RCA, until you are finished and are ready to document your findings.  PLEASE do not bog-down your team in drawing a WHY Tree when you should be confronting stakeholders with evidence.