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The year was 2001. I walked into my new office. I’d spent life after college in the field, either performing, supervising, or inspecting industrial construction. I had intimate knowledge of pipeline regulations, which helped me land this new job. Little did I know what I didn’t know. Well, there I was in my office, excited for the future, trying to learn the ropes, when, a few minutes into my dream morning, my boss, the district director, leaned into my office and said, “We just had a major incident losing a mainline pump.” I was expecting “Good morning” or something along those lines. My smile left as I heard him say, “Rob, you need to do a root cause analysis.” I kept my cool, and without missing a beat, I said, …

Quite succinctly, this endeavor draws and creates champions. If you are new to this field of investigations and have not yet been “hooked” by RCA, be prepared: you are likely to become a passionate advocate. It feels good to know that you are involved in a quest to make all our lives better.

The key to organizational success is bringing together a skilled group of people to work as a team toward an agreed-upon goal. It’s easy to say, but it seems to be derailed quickly.

Existing organizations are loaded with robust management systems in place and very skilled people.  They have clearly defined the vision or goal.  Yet success would not be the first adjective used to describe their results. 

In classes, I always discuss problem-solving and why we need it. I tell everyone that they are gifted problem solvers. I know this because they have jobs. Their employer would not hire and invest in them if they weren’t talented problem solvers. The ultimate goal of problem-solving is to overcome obstacles and find a solution that best resolves the issue. We need problem solvers.

Have you ever noticed how we tend to blame one another when something goes

wrong? This tendency to blame can be damaging and unproductive. Instead of looking

for external reasons to explain our unhappiness or frustration, we should look within

ourselves and acknowledge our thoughts, words, and actions in response to problems.

A survey of organizations across the US found that 74% of respondents believed

Imagine a family farm.  Somewhere in the Midwest, a farm exists whose purpose, or mission statement, is to plant, grow, harvest, and sell healthy big ears of corn.  They go about fulfilling that by using people who till the soil, plant, irrigate, harvest, and market the corn.  These people do this with various equipment, tools, and knowledge by following procedures, policies, rules, and guidelines already put in place to help fulfill the purpose.  These may be written or unwritten.  The operation is simple and very successful.  Like many others, they have overlooked the most critical element of any system.  What did they forget?  Culture. 

"There are many “Root Cause Analysis” methods, procedures, and approaches on the market today.  None of these methods define “root causes.”  They say they do, but they do not.  No-one can agree on what a “root cause” is, and yet most people say they’re defining “root causes.”  Saying it differently, everyone says they do “Root Cause Analysis” these days, and yet everyone is doing something different.  Think about it…"

"There is a fundamental problem with most organizations.  Their management system's purpose is to control the business.  A new purpose should be to learn and control the business. 

Over the past few decades, we have greatly improved our systemic approach to business.  In fact, the pendulum has swayed too far in that direction.  A system is made up of parts working together for a common goal, like ....

"Our phone rings when something catastrophic occurs.  Someone, in their organization or community, experiences a failure that stops them from continuing in the normal routine of life.  They need an independent investigator to lead the effort to learn what happened and understand it to an extent that we can move forward with a high level of confidence that it won’t be repeated.  Before I get off the phone, I already know what we're going to find, small unresolved problems."
"Try taking notice of the damage being caused by our human tendency to “blame one another.”  Notice what happens when something goes wrong in your life, either at home, within your community, or at work.  Listen to what people say, and observe how they behave.  More importantly ...." 
"Does your organization prefer to end its inquiries with system-type “causes?” If so, you will end-up wrapping yourselves into a tighter and tighter ball of checklists, procedures, and other rigid controls that are impossible for people to dwell in. Please do not go down this path. Learn from those who have. It is a dead-end, and often a fatal one."
"Because of our human tendency to avoid questioning the  familiar,  the  author  of  this  paper was stymied when Safety and Risk were studied from a different perspective.  Asphaliah (phonetic  spelling) is the Greek word for safety.  Beginning with the Greek, and then exploring our human understanding of Safety and Risk from a variety of perspectives, this paper
draws some conclusions that are thought-provoking, and a bit disturbing."
"Having become recently immersed in the paradigms of Nuclear Power Generation, especially as they relate to “human  performance,” the author is somewhat aghast at the current trend in thinking:  “We have finally figured out how to operate our equipment without failure – now we’re going to do the same with the human.”  Human beings have always been the same, and will always be the same.  We make mistakes.  Interestingly, ..." 
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