The Latent Cause Analysis
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Recognizing that ALL failure is caused by PEOPLE, and that all people learn IN RETROSPECT, all people that contributed to this event will be considered a STAKEHOLDER. All STAKEHOLDERS will be part of the stakeholder team. No stakeholder will be allowed to blame this incident on any other person or thing. Instead, all stakeholders will be required to see themselves as PART of the causes of the incident. In return for this open and honest reflection, the management of this organization promises that they will not punish anyone as a result of this LCA.
Advocates are the nurturing entity that helps people inculcate a latent cause mentality throughout an organization. It is comprised of people who are trained and available to investigate incidents, to help others investigate and lead the LCA effort at your site. It is a group of people that has banded together to make invisible issues visible. The creation of an advocate group is the single most important step towards changing an organizational culture in a positive direction. It is typically a group 1 person per hundred in an organization (or 5 or so individuals for a 500 person organization) that feel the responsibility of making "latent cause thinking" a part of an organization.
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 LCA is impossible because LCA'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! LCA's must be EVIDENCE-DRIVEN.
The Golden Rule of a Latent Cause Analysis
When something goes wrong, we will try to understand why people did what they did to such an extent we're convinced we would have done the same thing if we were that person.
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 LCA'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.
Inculcation (with respect to Latent Cause Analysis)
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 the word used to describe the effort to involve everyone in addressing the small problems in their lives. It acknowledges a need to ingrain a latent 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."
Latency (with respect to Latent Cause Analysis)
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.
Latent Cause Analysis
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.
LCA's are performed on any size of events. The rigor of the investigation is commensurate with the consequences. By definition, they always involve evidence-gatherers, stakeholders, and always define Physical, Human, and Latent Causes.
Latent Cause Mentality
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, as well as a growing understanding that "small problems matter."
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)
Root Cause Analysis has become "whatever people want it to be." There are so many variations of "Root Cause Analysis" these days that it has become almost meaningless. 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.
Root Cause Conference
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.
The Significant 6 Barriers to Latent Cause Discovery
A series of statements, articles, and graphics intended to make the REAL issues visible -- VERY visible.
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 it replaces BLAME with UNDERSTANDING so that REAL CHANGE can occur.
The SMART acronym is often used to help people write meaningful ACTION ITEMS. There are many variations of SMART. The one used by Failsafe is as follows.
Action Items must be:
A stakeholder (with respect to latent 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).
The 3 Ps
People Physical, and Paper Evidence
The 4 Ps
People Position, Parts, and Paper Evidence
The Vector Approach to Evidence Gathering
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 higher consequence 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 LCA.
CAUTION: Constructing a WHY TREE is NOT the same as doing a Latent 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.