8 - You have to know what you are trying to do if you are going to eventually do it

We have met the enemy and it is us!

Every failure can be traced to inappropriate actions made by people -- people who knew full-well that they did something they ought not have done -- caused by a flaw they already knew about and perhaps have been living with for years.  It's not that people intend to cause problems by ignoring these flaws.  Instead, people do not think these flaws matter.  We all fall into this trap.  This is the Merry-Go-Round.

If you recall, in one of the earlier articles I suggested that "failure" is one of the primary ways for people to "see" the Merry-Go-Rounds in their lives (the flaws we already know about but have buried in our subconscious).  If you think about it, failure (unexpected, unplanned pain) is the only way to "wake people out of their slumber."  We all need to be awakened.

When something goes wrong, therefore, and we decide to do a Latent Cause Analysis, we will require the right people to look at themselves as a result of something that has gone wrong, and we will not allow anyone to point fingers at other people and things.  This is the great uniqueness, as well as the great advantage of Latent Cause Analysis.  It's an overt attempt to make the Merry-Go-Rounds of our lives visible.

Allow me to be more blunt.

If you have read all the articles in this introductory series and have come to agree that people cause all problems within the systems they create (they either do things they should not have done or do not do things they should have done), then I hope you'll also agree that our ultimate objective ought to be to change people.  Although changing equipment or systems might help to a limited extent, the problem underlying the equipment or system will still exist if the people that create and maintain these things do not change.

But when I say that we need to change people, I certainly do not mean that we ought to merely "change them out" by replacing them with new people.  The new people would probably end up doing the same things as the replaced people.  It's people's behavior that needs to change, not the people themselves.  Things go wrong because people behave inappropriately.

Latent Cause Analysis requires the right people to look at themselves as a result of something that has gone wrong because this is the first and vital step in changing their behavior.  Once people genuinely confess that they have, in fact, behaved inappropriately, they are ready to consider why they behaved in that manner.

So let us suppose the right people have "confessed" their inappropriate behavior.  Now it is time to consider why these people behaved in the manner they behaved. 

Have you ever wondered why you behave the way you behave?  This question is easy to answer if we keep it simple.

All human behavior is caused by the thoughts going through our minds at the time of our behavior.

Everything we do, certainly all voluntary acts, but even the involuntary breathing and beating of the heart, is caused by the activity going through our brains at the time.  In other words, it's our thoughts that cause our behavior.  It's our thoughts, therefore, that ought to be the ultimate target of a Latent Cause Analysis. 

Things that go wrong offer a tremendous opportunity to change the way people think.

When everything is going well, when there are no problems occurring anywhere, when profits are soaring and everyone is smiling, there is no reason, incentive, or even use of changing anyone!  After all, everything is going well!

But when something goes wrong, then everything suddenly changes.  The mere suggestion that "something has gone wrong" is an inference that someone, somewhere did something they should not have done (more likely, some group of people did somethings they should not have done).  Prior to the event, everything was going right and there was no need for anyone to change anything.  After the event, everyone acknowledges that something has gone wrong and that there is a necessity to change something.

Allow me to give you an example.

Let's suppose a chemical plant experiences an explosion.  I'm using an extreme example to make my points, but the same thing applies to smaller problems.

In response to such an incident, the standard Latent Cause Analysis process requires an outside investigative leader and three evidence-gathering helpers to come into the chemical plant to take control of the evidence gathering process.  It is important to get outsiders in order to combat the bias and defensiveness that will exist -- the larger the consequence, the greater the bias.  We'll talk much more of the need for outside evidence gatherers in other training modules.

Initially, these four people's job is to gather evidence as soon and thoroughly as possible.  As they are in the process of freezing the evidence, they will find things that are obviously askew -- things which contributed to the incident.  They will be surprised, shocked, and often aghast at much of what they have found.  They, themselves, will have profoundly changed the way they see life as a result of this evidence gathering process.  This is not an exaggeration.

When people discover things, it changes them -- often instantly and permanently.  Examples of this are as varied as life itself.  Imagine how you felt the first time you picked up a rock and saw insects scurry into the darkness, or the first time you saw your own blood cells under a microscope, or the first time you burned your little hand on the hot stove, or the first time you saw the reaction on the other person's face when you treated them poorly.  It's life's discoveries that change us, both individually and corporately.

none of us will ever change the way they think (or the way we see life) until we've discovered something that challenges the old way of thinking.

With this in mind, let's get back to the chemical plant explosion.

The four outside evidence gatherers will have discovered things in their evidence-gathering efforts that will have changed them forever.  Unfortunately, however, these four outsiders will eventually leave the chemical plant.  After all, they're outsiders.  Therefore, the very people who have learned the most will eventually leave the plant.  They'll probably write a report and try their best to convey their findings, but as I've said in the above paragraphs, the real change occurs when "the evidence of life" is encountered -- face-to-face.

Therefore, when doing a Latent Cause Analysis the four outsiders will ask themselves "who needs to see this evidence we have gathered?"  In other words, they'll ask themselves "who needs to change the way they think as a result of what we've seen in the evidence?"  The four outsiders will acknowledge that they, themselves, have changed.  But they will also acknowledge that they are not the primary people that actually need to change. 

Let's review a bit, before moving on. 

When something goes wrong, it is imperative to gather evidence.  As the evidence is being gathered, it will become obvious that certain and specific people ought to be confronted with the evidence.  By "confrontation," I mean a mandatory and overt effort to assure that certain people see the evidence.  The people that need to be confronted with the evidence will be called the stakeholders of the incident.  Stakeholders are people that need to change the way they think (as inferred from reviewing the gathered evidence).

Once the stakeholders of the incident are identified, the summarized evidence will be presented to them in a very specific manner -- a manner which will assure that they have seen and digested it. 

Make it impossible for the stakeholders to ignore the evidence.

As the stakeholders are being confronted with the evidence, they will experience the same conversion as the evidence gatherers had experienced.  The evidence itself, presented in a specific and controlled manner, will literally change the way the stakeholders think.  The change will be immediate, and the change will be permanent.

I understand if you think this sounds too good to be true, but it's real.  I've seen it work, first hand, with me.  I have changed after being confronted with the evidence of life.  I have seen others change in the same manner.  Actually, this is how all of us change whether we know it or not.  And think of what it means if all this were not possible -- if it was not possible to change the way people think.  It'd be hopeless.  Life is not hopeless!

What are we trying to do with Latent Cause Analysis?  We're trying to change the way people think!  And this is far from a hopeless endeavor.

Important Points:

• Every failure can be traced to inappropriate behavior (actions or in-actions) made by people.
• People know full-well that they behave inappropriately, but they do not think it will hurt anything or anyone.  They think they behavior does not matter.
• All behavior is caused by the thoughts going through the person's mind at the time of their behavior.
• When something goes wrong, our ultimate objective ought to be to change the way people think.
• Things that go wrong offer a tremendous opportunity to change the way people think.
• Asking people to acknowledge their inappropriate behavior in an incident is the first step towards changing the way they think.  No other phenomena of life offers this same opportunity.
• None of us will ever change the way we think (or the way we see life) until we have discovered something that challenges the old way of thinking.
• When people discover things, it changes them -- often instantly and permanently.
• When something goes wrong, outside (unbiased) evidence gatherers freeze and summarize evidence. 
• Once the evidence has been frozen and summarized, the evidence gatherers identify people who need to be confronted with the evidence.  These people are called "stakeholders."
• Make it impossible for the stakeholders to avoid seeing the truth in the evidence.

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