tag:blogger.com,1999:blog-9932612Sun, 27 Nov 2011 23:26:54 +0000Litmus Testzero-based root cause analysisEvidnecewhat you can learn from things that go wrongreportschronic failureTom Stylesmother sourceROOTScomprehensive-all inclusivepick listslatent cause analysis templateGo ConceptGo BagNTSBlatent cause mentalitywhy treephysical human and latent causesfault treeevidenceEvidence Gathering3 Psblame virus1 techniqueCSIGo Box5latent cause analysisLatent Cause Experienceroot cause analysiseither-orsporadic failureroot cause analysis template3yahoo groupopen mother sourcebiasdiscoveryA Collection of Thoughts about Latent and Root Cause Analysis per C. Robert Nelms at Failsafe Network, developer of The Latent Cause Experience, the Maxi-RCA, Midi-RCA, Mini-RCA, WHY Trees. Extensive RCA Training and Consulting are available through Failsafe.http://failsafe-network.blogspot.com/noreply@blogger.com (C. Robert Nelms)Blogger18125tag:blogger.com,1999:blog-9932612.post-4157145934328262489Tue, 03 Aug 2010 14:55:00 +00002010-08-03T11:06:58.592-04:00I recently received an email that I simply must share. It's about the value of WHY Trees (or Cause Maps, or any other form of diagramming). Yes, these tools have value. But don't get pulled into the muck! BEWARE! The following is the email I received.==========I recently helped facilitate a Latent Cause Analysis where one of the stakeholders (an engineer!) had to do a cause map in order to http://feedproxy.google.com/~r/blogspot/CMkZ/~3/NRNvMQCWcRY/why-tree-no-no.htmlnoreply@blogger.com (C. Robert Nelms)2<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/NRNvMQCWcRY" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/08/why-tree-no-no.htmltag:blogger.com,1999:blog-9932612.post-8406549722756800916Wed, 24 Mar 2010 12:48:00 +00002010-03-24T09:00:30.718-04:00It is probably true that you will never learn anything that someone else didn't already know. If this is true, then shouldn't we spend a lot of time learning from other people? Let's explore this a bit....Before I was born, people knew how to walk, talk, eat, etc. And then, I was born.I know how I learned to walk, to talk, to speak in public, to write, to breath, to comb my hair (what’s left http://feedproxy.google.com/~r/blogspot/CMkZ/~3/Ooi0XxDIxzE/zero-based-root-cause-analysis-2.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/Ooi0XxDIxzE" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/03/zero-based-root-cause-analysis-2.htmltag:blogger.com,1999:blog-9932612.post-629518603135266357Wed, 24 Mar 2010 11:14:00 +00002010-03-24T08:48:10.169-04:00biasdiscoverypick listszero-based root cause analysisI recently viewed a slide show about Foreign Material Management, i.e., making sure the wrong stuff doesn't get into our systems. It was based on learning's from past investigations, and was an excellent slide show.We have learned an enormous amount about why things go wrong through investigating past incidents. Obviously, it is imperative to share what we've learned so that others do not http://feedproxy.google.com/~r/blogspot/CMkZ/~3/RkbPqlOXH8Y/zero-based-root-cause-analysis-1.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/RkbPqlOXH8Y" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/03/zero-based-root-cause-analysis-1.htmltag:blogger.com,1999:blog-9932612.post-1503549495231662981Fri, 19 Feb 2010 18:35:00 +00002010-02-19T14:05:15.584-05:00Go BoxLatent Cause ExperienceGo BagEvidneceEvidence GatheringIn November, 2009 I had the good fortune to have been invited to Billings, Montana to present Failsafe's 4-day Latent Cause Experience. I was invited by Tim Mullowney, a person I met in Billings several years ago at another seminar I presented to his company. Tim and I "clicked" almost immediately, as we share many core values and beliefs. We don't talk incredibly often, but good friends don'thttp://feedproxy.google.com/~r/blogspot/CMkZ/~3/S9Q4MR_s5AM/best-go-bag-or-go-box-ive-ever-seen.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/S9Q4MR_s5AM" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/02/best-go-bag-or-go-box-ive-ever-seen.htmltag:blogger.com,1999:blog-9932612.post-1141096047717608134Tue, 16 Feb 2010 12:25:00 +00002010-02-16T08:45:54.233-05:00Go BoxevidenceNTSB3 PsGo BagGo ConceptTom StylesLitmus TestIn the early 1980's, while working for Allied Chemical Corporation in Hopewell, Virginia, I had extraordinary freedom to quench my thirst for "why things go wrong."Since I was living about 2 hours from Washington D.C. at the time, I was able to travel there often. I visited museums, the National Archives, as well as NASA and National Transportation Safety Board (NTSB) headquarters. In my readinghttp://feedproxy.google.com/~r/blogspot/CMkZ/~3/ogXVhUH7Ro4/ntsbs-go-concept.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/ogXVhUH7Ro4" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/02/ntsbs-go-concept.htmltag:blogger.com,1999:blog-9932612.post-937223614337491567Thu, 04 Feb 2010 12:22:00 +00002010-02-04T18:12:52.640-05:00why treesporadic failureCSIchronic failureI've written about WHY Trees twice in the recent past, first to describe their origins and secondly to describe a gross problem in the way they are being used. I'd like to end, at least for the time being, by sharing my thoughts about the present value of WHY Trees.Actually, these BLOG posts about the WHY Tree are in response to growing criticism that I have gone too far in my dismissal of their http://feedproxy.google.com/~r/blogspot/CMkZ/~3/0o5mAbVz9cE/present-value-of-why-tree.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/0o5mAbVz9cE" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/02/present-value-of-why-tree.htmltag:blogger.com,1999:blog-9932612.post-7535623409009150063Tue, 02 Feb 2010 18:40:00 +00002010-02-03T07:10:54.139-05:00evidence1 techniquewhy treecomprehensive-all inclusivewhat you can learn from things that go wrongeither-orfault tree35In a past post, I tried to explain a little about the origins of the Why Tree. As I said, they are a spin-off-of Fault Tree Analysis. Fault Trees, however, are classically constructed in the design phase of a project to help determine the mathematical probability of specific, catastrophic events.Why Trees were originally developed by myself to help an investigator navigate through an http://feedproxy.google.com/~r/blogspot/CMkZ/~3/n0DZPD3Mf2U/problem-with-why-trees.htmlnoreply@blogger.com (C. Robert Nelms)1<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/n0DZPD3Mf2U" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/02/problem-with-why-trees.htmltag:blogger.com,1999:blog-9932612.post-2374372831337846430Mon, 01 Feb 2010 19:02:00 +00002010-02-03T06:51:20.507-05:00latent cause analysisroot cause analysis templateROOTSlatent cause analysis templatereportsWeb-based Latent Cause Analysis?It is admittedly gratifying to experience the energy and enthusiasm that accompanies almost all 4-day Latent Cause Experience Classes. It is even more satisfying when I get letters from some of you to tell me of some personal changes that you've made because of the key question:What is it about the way I am that contributes to my problems?It'd be easy to "pat http://feedproxy.google.com/~r/blogspot/CMkZ/~3/05g4pg4jmPg/web-based-latent-cause-analysis.htmlnoreply@blogger.com (C. Robert Nelms)3<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/05g4pg4jmPg" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/02/web-based-latent-cause-analysis.htmltag:blogger.com,1999:blog-9932612.post-1527689889723517767Mon, 01 Feb 2010 18:10:00 +00002010-02-02T13:30:47.200-05:00why treefault treeWhere did the WHY Tree originate?I become aware of Fault Trees in the 1970's. This was almost inevitable, given that I was a chemical plant reliability engineer at the time, and was charged with researching the "state of the art" respecting reliability principals.I discovered that Fault Trees were initially developed in the mid-1960's by Bell Labs to help evaluate the reliability of the Minutemanhttp://feedproxy.google.com/~r/blogspot/CMkZ/~3/NFl5XHE3iTk/birth-of-why-tree.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/NFl5XHE3iTk" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/02/birth-of-why-tree.htmltag:blogger.com,1999:blog-9932612.post-3772516903155517914Thu, 28 Jan 2010 15:48:00 +00002010-02-02T13:30:02.644-05:00latent cause analysislatent cause mentalityblame virusmother sourceA long-term part of Failsafe's approach to Latent or Root Cause Analysis (at least since 1994) has been my insistence on the need for a Mother-Source the help drive the process.Although not a very "manly" phrase, those who understand its intent and agree with its purpose insist on using it. In this respect, the phrase is almost like a litmus test to see who is qualified to drive the process that http://feedproxy.google.com/~r/blogspot/CMkZ/~3/vBtZXnWe26U/what-is-mother-source.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/vBtZXnWe26U" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/01/what-is-mother-source.htmltag:blogger.com,1999:blog-9932612.post-3538182853384577030Wed, 27 Jan 2010 14:07:00 +00002010-02-08T08:50:53.938-05:00latent cause analysisopen mother sourceyahoo groupROOTSmother sourceIn December, 2009 I announced my desire to facilitate an Open-Mother-Source (OMS).Several of you have responded favorably to this idea, so I will take it to the next step. I do have a initial "vision" for this, but I will as open an possible to go wherever the membership takes us.As I presently see it, the OMS is to be a periodic web-based meeting for people who are interested in promoting latenthttp://feedproxy.google.com/~r/blogspot/CMkZ/~3/6tm3svK0mPo/open-mother-source-forum.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/6tm3svK0mPo" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/01/open-mother-source-forum.htmltag:blogger.com,1999:blog-9932612.post-390049297176732881Thu, 21 Jan 2010 11:36:00 +00002010-01-21T09:04:46.780-05:00Sometimes I wonder about the intentions of companies who are doing "root cause analyses." I wonder why they are doing them. I remember that in the early days (1970's), suggesting that people do a root cause analysis was like suggesting that they get a root canal. Few, if anyone in the industries that I was serving (mainly chemicals) seemed very interested.Then along came OSHA 1910, and all the http://feedproxy.google.com/~r/blogspot/CMkZ/~3/vYELKBu7S3c/forced-to-learn-from-things-that-go.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/vYELKBu7S3c" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/01/forced-to-learn-from-things-that-go.htmltag:blogger.com,1999:blog-9932612.post-3775111083264184252Mon, 18 Jan 2010 19:52:00 +00002010-01-19T07:11:59.410-05:00physical human and latent causeslatent cause analysisroot cause analysisTwo years ago, in January 2008 I decided to listen to Failsafe's 4-day "Root Cause Experience" class attendees and change the name of Failsafe's pursuit from "Root Cause Analysis" to "Latent Cause Analysis."Class attendees pointed out a fact about Failsafe's approach to "root cause analysis" which made the phrase counter-productive. Since Failsafe's methods do not identify "root causes," why use http://feedproxy.google.com/~r/blogspot/CMkZ/~3/BZbOJ9QLOYY/death-of-root-cause-analysis-at-least.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/BZbOJ9QLOYY" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/01/death-of-root-cause-analysis-at-least.htmltag:blogger.com,1999:blog-9932612.post-7023166293974545639Mon, 18 Jan 2010 19:47:00 +00002010-01-18T14:52:14.502-05:00It's been quite a while since I last posted to this blog -- and one of the things I'll be trying to do this year is post much more frequently.So starting this month (January, 2010), I'm going to be sharing what I am thinking about, relative to Latent or Root Cause Analysis.If any of you who read this blog would like me to share my thoughts about anything in particular, please let me know. Either http://feedproxy.google.com/~r/blogspot/CMkZ/~3/uw8hmrSb1pc/its-been-long-long-time.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/uw8hmrSb1pc" height="1" width="1"/>http://failsafe-network.blogspot.com/2010/01/its-been-long-long-time.htmltag:blogger.com,1999:blog-9932612.post-111409239826474916Thu, 21 Apr 2005 13:45:00 +00002005-04-21T15:39:26.446-04:00While presiding over a fascinating 4-hour discussion, an upper-level manager asked in exasperation:What, exactly, do you mean when you say that I have to SLOW DOWN! The 4-hour discussion was prompted by two Root Cause Analyses that were presented by their Principal Investigators (PI's) to a group of 30 people who had just gone through 4 days of Root Cause Analysis training. Amongst the trainees http://feedproxy.google.com/~r/blogspot/CMkZ/~3/6lgWmU5lHb0/slow-down.htmlnoreply@blogger.com (C. Robert Nelms)4<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/6lgWmU5lHb0" height="1" width="1"/>http://failsafe-network.blogspot.com/2005/04/slow-down.htmltag:blogger.com,1999:blog-9932612.post-111385276456150896Mon, 18 Apr 2005 19:14:00 +00002005-04-20T11:50:35.146-04:00I am bothered, and this is my place to vent. My feelings come from some recent comments coming from the www.rootcauselive.com forum.An unnamed organization revealed that even after experiencing some very well-received Root Cause Analysis training it is struggling to inculcate a root cause mentality. The organization asked for advice.I requested that forum members suggest specific, actionable http://feedproxy.google.com/~r/blogspot/CMkZ/~3/D3nT9N_zv7g/do-you-want-to-be-on-merry-go-round.htmlnoreply@blogger.com (C. Robert Nelms)4<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/D3nT9N_zv7g" height="1" width="1"/>http://failsafe-network.blogspot.com/2005/04/do-you-want-to-be-on-merry-go-round.htmltag:blogger.com,1999:blog-9932612.post-110795020591403559Wed, 09 Feb 2005 11:33:00 +00002005-02-09T07:13:08.730-05:00When I am hired to teach Root Cause Analysis to an on-site group of people, one of the most common questions I hear is "does our management know what you're teaching us?" My generic answer is "no!" In my experience, most managers and executives think that Root Cause Analysis is something done by engineers and other technically-inclined people on either complex, long-term problems or the sudden http://feedproxy.google.com/~r/blogspot/CMkZ/~3/5TiZGtHXkT8/do-managers-know-what-root-cause.htmlnoreply@blogger.com (C. Robert Nelms)1<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/5TiZGtHXkT8" height="1" width="1"/>http://failsafe-network.blogspot.com/2005/02/do-managers-know-what-root-cause.htmltag:blogger.com,1999:blog-9932612.post-110545745833362620Tue, 11 Jan 2005 18:25:00 +00002005-01-11T10:33:04.080-05:00Failsafe Network is a small consulting company that focuses on organizational and individual Root Cause Analysis. It is recognized that Blogs and their syndication are the wave of the future. Therefore, this trial is being undertaken to experience the usefulness of the concept. It is hoped that several times a week, C. Robert Nelms (President and founder of Failsafe) will contribute relavent http://feedproxy.google.com/~r/blogspot/CMkZ/~3/KjTviPpacJ4/introducing-failsafe-network-blog.htmlnoreply@blogger.com (C. Robert Nelms)0<img src="http://feeds.feedburner.com/~r/blogspot/CMkZ/~4/KjTviPpacJ4" height="1" width="1"/>http://failsafe-network.blogspot.com/2005/01/introducing-failsafe-network-blog.html