PRCTL offers Professional, Quality services...                   Practical Solutions for the Energy Industry...


Back

Home Back Services Contents News

 

 


Archived Latent Cause Analysis "Food for Thought"           


 

Rob Statham

Mini LCA  

Apathy?  Helplessness?  Hopelessness?  Does this sound like your work environment?  Do you feel powerless to change what you know needs to change?  There is HOPE!  There is HELP!  You are in a race.  It is the Rat Race.  Are you tired of chasing your tail?  There is a way to break the ever numbing cycle of the rat race and discover POSITIVE change.  We need positive change in our work place.  No one needs another initiative that will fade away in a year or two.  That is part of the problem.  The other BIG part of the problem is the way we think.  People may be apathetic but honestly it is for a good reason.  People see what needs to change but it NEVER changes.  Anyone that experiences this over and over is pulled towards apathy.  Once we move towards apathy then we are contributing to the very problem we hate!  How can you change it? 

The answer is actually very simple.  Start doing Mini Latent Cause Analysis (LCA).  Mini LCA’s take an hour or two to complete.  How can an hour change things, you ask?  The power of the Mini LCA is twofold. 

First, by doing Minis you will effectively identify the significant latencies that are causing that helpless feeling and also a majority of your painful problems.  Minis isolate the person doing them so that they SLOW DOWN and look at themselves.  Honestly look.  Minis help eliminate so much of the noise that hides our problems.  We like to think we have no part in what went wrong and it was someone else’s mistake.  You bypass that thought process doing Minis.  You have to understand, based on evidence, what happened physically.  There is great value here, but we do not stop here.  You will also “see” who did what wrong.  We NEVER STOP HERE.  This is the springboard to UNDERSTAND why that person did what they did so YOU can see the powerful latent force at work that caused the problem.  In fact you not only see it, you have EVIDENCE that it caused a problem.  Granted these are small problems.  Imagine if 100 people did 4 of these a year then you would have 400 Minis in a year.  You see that over 300 problems (that is almost one a day!) were caused by the same latency.  This is a gold mine!  Effectively address ONE LATENT CAUSE and you have evidence that it will remove HUNDREDS of future problems and also BIG problems.  This alone is worth more than gold.  WE are not done. 

Second, you (one person) look in the mirror.  You “see” that you actually contribute to the latency that has caused the problem and is still causing other problems.  The moment a normal human being understands that their actions contributed to a problem they CHANGE.  People are not aiming to cause problems.  In fact they are problem solvers and aiming to avoid problems and produce quality for the company.  When you “see” that you are causing, or contributing, to the problems – YOU CHANGE.  This is true for Mangers, Supervisors, Field personnel, or office help.  The Mini LCA, done appropriately, can CHANGE THE WAY YOU THINK.  This will help change the way your culture thinks, one small step at a time.  The more Minis that are done, the closer and closer you move toward a Latent Cause Mentality.  The further you move away from apathy and see that things can change for the good and you can contribute to positive change.  This is a snowball waiting to get pushed down the mountain.  You can start it moving!

Why wouldn’t  you want to ask your employees to spend 8 hours per year in order to improve your business?  Because you don’t believe it can happen or maybe you simply just do not understand?  Changing the way people think is only 8 hours per year away or if you prefer 2 hours per quarter or 36 minutes per month or well you get my point; there is no reason not to.  But why then is it so difficult to accomplish.  I am referring to the Mini LCA.  Asking your employees to transform the way they think through the Mini LCA is not only easy, but extremely rewarding.  In fact don’t ask your employees to do Minis without doing them yourself.  Lead by example!  We ALL can learn from things that go wrong and the learnings will transform the way you live, do business, and work as a team.  We all understand improved business no matter what your definition of improved is, but we all struggle with initiatives that create more work when we do not even have time to complete what we already have on our plate.  Call me crazy, but I firmly believe that doing minis will help remove things from our plate because we will learn to be more efficient.  Doing Minis is not an initiative but rather a transforming eye opener for all to learn from things that go wrong.

 

One "Mini LCA" changed my life

I think doing Mini’s is what helps you see yourself as part of the problem.  

I went to the 4-day in 2001 and thought this was the best thing I have ever heard.  I loved this process.  At the end of class Bob said he would send you a certificate if you went home and did a Mini and send it to him.  I wanted a certificate – this was going to transform the way we did business.  

I went home and voila, my nephew went out my back door and the bottom step collapsed.  He did a couple of somersaults and popped up.  It was funny.  He was 15 and made out of rubber – he was fine.  I thought “this is great.  I can do my Mini and get my certificate.”  

 I started in on the Mini.  A simple Mini on a broken step – this should take me about an hour.  IT TOOK ME A WEEK!  I would work on it and stop, and work on it and stop.  You get the idea.  I was SO UNCOMFORTABLE looking at myself.  I was embarrassed.  I didn’t want anyone to see what I was seeing.  I was fired up to show my coworker how they contributed to a failure but this was at home and I was looking in a mirror.  I even thought about making up a failure and then came to my senses.  During the course of the week I realized something - what I saw was the TRUTH.  Like it or not, it was true.  You see, I knew about the problem with the steps about 6 months before they broke.  I was lazy.  I would rather watch football than take care of that step.

The other thing I realized is that my elderly parents were there visiting and it could have just as easily been one of them that did a couple of somersaults.  I was sick.  I sent in the Mini-LCA, embarrassed and sick.  

It changed my life.  I am far from perfect but I have changed the way I think.  

 

Spencer Philo

Blame

BLAME makes me sick!  Blame is the most significant roadblock to positive change! He did not read the procedure! She did not do an MOC! It wasn’t me it was you!  This is all blame and until we get over it we will not change or learn from things that go wrong.  I do it, you do it, most everyone around us does it, but until we let go of blame we will not learn everything we can from things that go wrong.  Sure we will learn that the valve lifted and this is usually where we stop.  We found out why the failure happened; the valve lifted!  Some organizations want to understand, so they ask “why did the valve lift”.  Well, the valve lifted because the differential pressure was lost.  But why was the differential pressure lost?  Because the differential pressure sensing line was plugged.  Why was the differential sensing line plugged?  Because the differential sensing line root valve was plugged.  Why was the differential sensing line root valve plugged?  Because the wrong valve was installed which allowed sulfur to build up in the valve body and plug the valve.  BINGO we found out who did it!  The engineer put the wrong valve in.  The operator new this was the wrong valve.  The inspector looks at this valve every day why didn’t he catch it.  What should we do?  Move on and attempt to understand more.  Do not stop here!  Did you hear me, DO NOT STOP HERE!  This is blame, find out who did what wrong and stop.  Now let’s ask why.  Why was the wrong valve installed and not recognized.  If we let go of BLAME and try to understand to such an extent that we would have used the same valve, we will truly learn from things that go wrong. 

 


Information Request

    Send us your Comments

Home ] Back ]

 Information Request

Send mail to webmaster@PRCTL.com with questions or comments about this web site.
Copyright © 2005 PRCTL
Last modified: 03/12/10