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.
It is finally time to wrap up this introduction with one more example, and a few more vital points.
Latent Cause Analysis is not a guessing game, nor the "blame game," nor a vague and impractical psychological exercise that yields little fruit. It's vitally decisive, in fact life changing as I mentioned numerous times in past articles. Latent Cause Analysis is surgically precise, proceeding step by step into the invisible causes of a failure (pushing back the cloak of the unknown) until the right people have "changed the way they think" by being confronted with evidence.
A refinery on the West Coast of the USA experienced a major unexpected shutdown because of a sudden loss of steam pressure. One of the steam generators (boilers) suddenly went off line because the pump that fed water into the boiler failed unexpectedly (and the backup pump was not available).
As suggested in the last article, outside evidence gatherers were sent into the area and quickly found the immediate cause of the pump failure: The pump's drive shaft was cracked into two pieces.
Maintenance was called to remove the drive motor so that the shaft could be inspected more closely. When it was inspected, the evidence gatherers immediately saw the classic markings of a "fatigue failure." A metallurgist was quickly brought to the scene, who said the fracture surface was indicative of "bending back and forth over a long period of time (and many cycles)."
When the metallurgist viewed the fracture through a microscope, she was able to approximate the number of cycles to failure - months in this particular case. She told us she knew of only one way for a failure like this to occur -- there must have been an angular misalignment between the drive motor and the pump.
Evidence gatherers scurried to find the causes of the misalignment, and found (through evidence gathering) that the mechanic that installed the pump did not properly align it with the motor. The following diagram (called a WHY Tree, discussed in much more detail in later modules) shows what the evidence gatherers learned as they followed the evidence (pushing back the cloak of the unknown), making the invisible, visible.
This is a true story, although I am simplifying it for the purposes of this introduction.
Note the surgically precise learning's as the evidence gatherers "pushed back the cloak."
Latent Cause Analyses start with a "physical failure," i.e., something that physically manifested itself, the "dandelion on the lawn." It is important to start at this physical manifestation, the top-down (outside-in) problem I wrote about earlier. If you do not understand what I mean by "starting with the physical manifestation," then simply ask yourself "how did we know the incident occurred -- what initially manifested itself to our senses?"
As described above, the first activity in response to the "physical failure" is to gather evidence (I will say much, much more about evidence gathering in the following modules). As the evidence gatherers uncover deeper-level causes (that were previously behind the cloak of the unknown), they acknowledge them on the WHY Tree (above).
Note, however, that the initial focus is on understanding the PHYSICS of the event. To be honest, many people are so enamored by "getting people to look at themselves" that they do not spend enough time on understanding the physical causes of an event. But understanding the physical causes of an event is an absolute necessity to doing a proper Latent Cause Analysis.
Focus on the physics first!
Once the physics are thoroughly understood, it is proper and vital to find the Human Causes.
The red box below is called the "Human Cause" of this event. There is always a Human Cause (and almost always more than one). Human Causes answer the question "who did what wrong."
Once we have identified the Human Cause(s), now we are ready to reveal the Latent Causes.
As discussed in a previous article, all Human Behavior is caused by the thoughts (or lack of thoughts) that go through the mind of the person at the time of their behavior. The only exception to this is when a person is physically or mentally ill, i.e., when the body does not do what the mind "tells" it to do.
Therefore, the next step in our example is to determine the thoughts that went through the mind of the mechanic at the time he was doing the alignment.
For the purposes of this example, I will summarize the mechanic's thoughts as:
"It is okay to take shortcuts."
In other words, this mechanic knew that he was doing something "more quickly" than suggested in his training. Even more, he thought it was "okay" to do this!
The "domino" has become much wider!
It is wider because this person is carrying an attitude, i.e., is walking around on a Merry-Go-Round on which it is normal to take shortcuts. This attitude, or thought pattern, is latent within the mechanic and will definitely cause future problems.
Of course, there are reasons why this mechanic thinks it is okay to take shortcuts. This particular mechanic was a 20 year employee, working all his years at this West Coast refinery. He did not wake up one morning and decide that he would not use his training anymore. More generally, people do not wake up in the morning with the intent of causing problems (and if they do, then get rid of those kinds of people -- we are not talking about them here).When this person was hired into this plant 20 years before the incident, he was similar to a freshly picked cucumber. All employees, when freshly hired, are similar to the cucumber -- even more when the employees are young and have never worked anywhere before.
But think of what happens when the new employee comes to work the first day, then experiences his first week, month and year. Day after day, the new employees are immersed in "the way things are around here."
They are immersed in pickle juice!
We all know what happens to a cucumber that is immersed in pickle juice. It becomes a pickle. Latent
Please note how futile it would be to "punish the cucumber for turning into a pickle?" What other outcome could there have been? Even worse, imagine "firing the pickle," and then hiring a new cucumber -- immersing it into the same pickle juice!
Instead of doing something so ridiculous, would it not make more sense to ask:
What is it about the way we are that has influenced this mechanic?
The answer to this question are the "Organizational Latent Causes" of the pump failure. Organizational Latent Causes always begin with the word "we," and answer the above question.
Organizational Latent Causes are the "pickle juice," or the "Merry-Go-Round" that I have spoken about in the past. Most significantly, Organizational Latent Causes will influence other people to act in similar destructive ways if not addressed.
If you think about it, the only way to be proactive with any investigative method is to answer and act on the above question. Anything less than this will only be delaying the time until the next failure, instead of preventing all kinds of physical failures that have never yet occurred.
But this is certainly not the end-point. Answering the above question is productive, but often leads to internalized finger-pointing. If you think about it, answering "what is it about the way we are" often leads people to think "We don't do a very good job with _____. I do a great job, but everyone else falls short."
From the very beginning of this introduction to Latent Cause Analysis, I have been trying to convey the need for people to look at themselves instead of pointing their fingers at other people and things. Although Organizational Latent Causes are important, they are actually only a stepping stone to answering the vital, and life-changing end-question of a Latent Cause Analysis:
What is it about the way I am that contributed to this event?
The answers to this question are the "Personal Latent Causes" of the event, and are much more important than the Organizational Latent Causes. After all, "I" am part of the "we," and I am the only person I have control over. Saying it differently, I am a part of the "pickle juice," the "Merry-Go-Round" that we are trying to make visible -- the only part of the pickle juice I can CHANGE. The most important, essential outcome of a Latent Cause Analysis is for everyone to see themselves as part of the problem -- for everyone to define their own Personal Latent Causes.
As I begin to wrap up this introductory module, I feel a need for you to understand the following:
Latent Cause Analysis does not side-step the human issues. On the contrary, Latent Cause Analysis confronts them head-on. I personally know of no investigative method that directly and overtly focuses (at the end) on people as bluntly and effectively as Latent Cause Analysis.
This is the one investigative method where personal accountability is demanded of all.
In the above graphic, for example, the mechanic that improperly aligned the motor and the pump will be required to admit what he did, and then suggest what he should have done instead. He will be required to air his thoughts (that led to his behavior) to the best of his ability. The remainder of the organization will be listening, and will learn through him.
But it will not stop at the mechanic. The supervisors, trainers, foremen, plant engineer, maintenance manager, and plant manager will also be required to see themselves as part of the problem, after they have heard the dilemma posed by the mechanic (in this case). Finally, everyone will be asked to answer the question:
What is it about the way I am that contributed to this event, and what am I willing to do about it?
Imagine the culture change that will occur as you embark on this journey.
Important Points:
- Latent Cause Analysis is not a guessing game, nor the "blame game," nor a vague and impractical philosophical exercise that yields little fruit.
- Latent Cause Analysis is surgically precise, proceeding step by step into the invisible causes of a failure until the right people have "changed the way they think" by being confronted with evidence.
- Latent Cause Analysis initially attempts to understand the PHYSICS of the incident.
- It is a gross mistake to attempt to define Human and Latent Causes prior to understanding the Physical Causes of the incident.
- Once the physics are thoroughly understood, it is proper and vital to find the Human Causes.
- Human Causes answer the question "who did what wrong."
- There will always be more than one Human Cause.
- By "wrong," we do not mean "bad," or even that the person knew it was "wrong." By "wrong," we mean "wrong" IN RETROSPECT.
- Once the Human Causes are defined, Organizational and Personal Latent Causes can be defined.
- Organizational and Personal Latent Causes are defined by initially acknowledging the THOUGHTS that went through the person's mind when they did the "wrong" thing.
- Everything we do is caused by our thoughts.
- Our thoughts are influenced by our environment.
- Human beings are like cucumbers that are immersed in pickle juice. Over time, the cucumbers change. They become pickles.
- Organizational Latent Causes answer the question: What is it about the way WE are that influenced the human?
- Personal Latent Causes answer the question: What is it about the way I AM that influenced the human?
- The only way to be proactive with any investigative method is to answer and act on the Organizational and Personal Latent Causes.
- The only person I know I can change is me, so why not start there?
- Latent Cause Analysis confronts human accountability head-on. It is the one investigative method where personal accountability is demanded of all.
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