And its antidote C. Robert (Bob) Nelms Failsafe Network, Inc

And its antidoteC. Robert (Bob) NelmsFailsafe Network, Inc.

Everyone wants to change the world, but no-one wants to change

themselves…..

Leo Tolstoy, 1828-1910 (Russian author and philosopher)

Human Nature It’s not me, it’s you. It’s not us, it’s them. It’s not people that cause

our problems:◦ it’s our equipment.◦ it’s our systems.

Human Beings LOVE to BLAME!

14 statements were suggested to help rate the “health” of their site’s root cause analysis efforts.

Respondents were asked to rate the truthfulness of the statements at their place of business (scale of 0 to 5).

Oil and Gas was the most frequent industry respondent.

“Executive” was the level of the most frequent type of respondent.

Trends were largely scattered – with one exception.

Statement #13: ◦ “We have learned the futility of

blaming one another for our problems. Finger-pointing is virtually non-existent at our site (or Business Unit).”

74% of respondents said this was NOT TRUE at their sites.

Is there any doubt that most of us have been infected by the blame virus?

The Blame Virus

A quick vote.

No known function

other than…

to take over the resources of its

victim

Cell Wall

Nucleus

Virus

Cell Wall

Nucleus

Cell Wall

Nucleus

Cell Wall

Nucleus

The Human Psyche

The mind, and its capacity to govern behavior

The Human Psyche

The mind, and its capacity to govern behavior

It’s not me, it’s YOU!

From http://www.yahoogroups.com/group.rootcauseconference

Hundreds of comments were made.

Comments were unanimously against the notion of BLAME.

I am going to share 4 of these comments (typical)..

..and then I’ll ask if you agree with the “essence” of the comments.

9:30


To my mind, "BLAME" is a negative force directed outwards from a person who

shies away from personal responsibility and is based on the

misconception; "I am above board - the fault lies elsewhere." A culture of blame

breeds complacency and decay. The viruses of ignorance and arrogance breed blame and the corresponding

negative forces of death and destruction…... Tony Fernandez


It doesn’t take phenomenal ability to realize that a person who is given blame learns how to avoid the blame next time,

while a person who gives blame learns nothing. As a result, things continue to go wrong... Bill Salot


I see blame as defensive and aggressive and a tactic to make sure

everybody knows I am not responsible in any way for what happened....

Mike Van Leuken


All blame is a waste of time. No matter how much fault you find with another, and regardless of how much you blame him, it

will not change you. The only thing blame does is to keep the focus off you when you are looking for external reasons to explain your unhappiness or frustration. You may

succeed in making another feel guilty about something by blaming him, but you won't succeed in changing whatever it is about

you that is making you unhappy… Wayne Dyer (author and speaker)


Do you agree with the essence of the comments?

13:00

Yes, people are almost always “at fault.”◦ Interpersonal relationship problems

Yes, people are almost always “at fault.”◦ Interpersonal relationship problems◦ When something goes wrong within a system

that we have created

Yes, people are almost always “at fault.”◦ Interpersonal relationship problems◦ When something goes wrong within a system

that we have created Therefore, it is NOT the premise of this

presentation that people are not at fault. People are almost always at fault.

Nothing about the

way we are contributes to our failures!

And most certainly,

nothing about the way I am contributes to our failures!

If everybody is looking at the other guy,who is looking at HIMSELF?

It’s partially “my fault.”

25:00

The best years of your life are the ones in which you decide your problems are your

own. You do not blame them on your mother, the ecology, or the president. You

realize that you control your own destiny…. Albert Ellis (American

psychologist)

When you don't take responsibility, when you blame others, circumstances, fate or chance, you give away your power.

When you take and retain full responsibility - even when others are wrong or the

situation is genuinely unfair - you keep your life's reins in your own hands…. Jeff

Olson (American author and speaker)

Never blame what you are on what someone else is… Wes Fessler (American author)

I blame my mother for nothing, but forgive her for everything…. Mary Blige

(Rhythm and Blues Singer and actress)

It simply makes more sensefor everyone to look at

themselvesinstead of everyone pointing their

fingers at others.

Agree?

It simply makes more sensefor everyone to look at

themselvesinstead of everyone pointing their

fingers at others.

But human nature being

what it is,

is this even

possible?

Small viral attack: Primary Immune System Response

29:30

Adjacent Cells Prepare Themselves

Small viral attack: Primary Immune System Response

Well would you look at that! What kind of an

idiot would have left the spigot on?

Small viral attack

BLAME ALERT – BLAME ALERT – BLAME ALERTBLAME ALERT – BLAME ALERT – BLAME ALERT

Well would you look at that! What kind of an

idiot would have left the spigot on?

That’s not the way we do things in this family,

Bruno.

We WILL NOT ACCEPT even a tinge of BLAME

Not even a tinge of BLAME

I knew the hose was pressurized with water

because there was a small puddle on the ground near the

nozzle for at least a week before we left. I guess I should

have told someone about it.


Oh my! I remember seeing it also – and didn’t do anything about it. I should have turned

it off myself!


I have to admit that I often leave the faucet on, even after I’m

finished for the day. I guess I’m thinking “why turn it off if I’ll use it tomorrow?” I’m the biggest

culprit!


Let’s all try to be an example to one another by not ever taking any shortcuts! In fact, let’s see who can

set the best example.

People cannot and will not feel responsible for

ANYTHING

when they are infected by the blame virus.

However, in the absence of the blame virus, each

person is FREE to see themselves as part of

the problem.

They are FREE to be INTROSPECTIVE.

Massive Viral Attack

Mass Invasion Alert!!!!!!

39:50

Massive Viral Attack: Calling the Secondary Immune System

Now wait a minute. Leaving a spigot open at

home is one thing. Sleeping on the job is quite

another. This is a termination

offense.....no excuses!!!!!

FAST

Contain then Restore

FAST

It’s the equipment, the systems, the vendor, the doctor, the nurse, Congress, the

President, anything or anyone except ME! So now that I know how it happened, and

who did it, get out of my way and let me do

something about this!

FASTSLOW

It’s the equipment, the systems, the vendor, the doctor, the nurse, Congress, the

President, anything or anyone except ME! So now that I know how it happened, and

who did it, get out of my way and let me do

something about this!

Intentional, Aggressive

Introspection!

FASTSLOW

The Causal Learning Function.The Root Cause Analysis Function.

The Latent Cause Analysis Function.

These functions ARE the organizational psyche’s secondary

immune system…

….IF their goal is to replace BLAME with INTROSPECTION.

Any causal learning function that discourages

people from looking at themselves is in itself a significant CAUSE of our

problems.

A suggested4-pronged

antidote to the blame virus…

…driven by a strong causal learning function at your

site.

We will attempt to engrain the Golden Rule of Things that Go Wrong in to all

our people.

“I will try my best to understand why people did what they did (especially if I

am tending to blame someone) – to such an extent I am convinced I would have done the same thing in a similar

situation.”

Note: getting to this point will guarantee that you understand.

We will attempt to make a no-blame mentality the norm for everything and anything that goes wrong within our

lives.

In anticipation of big things that go wrong, we will strive to obtain an official,

no-blame policy, and strongly re-emphasize it when such things occur (in

anticipation of a mass invasion of the blame virus).

We will insist on a corresponding self-discovery (introspection) mentality as the

norm for everything and anything that goes wrong within our lives.

In other words, our goal is for everyone to try their best to see themselves as part of

every one of their problems.

We anticipate this mentality being progressively detailed, i.e., it is suggestive

for small problems and required (in a specifically delineated format) for larger

ones.

When (if) a catastrophe occurs, we will encourage this policy to be strongly re-emphasized (in anticipation of a mass

invasion of the blame virus.)REQUIRED!

At work, we will try to make an Accountability Contract a condition of employment. The contract might reads as follows:

We, the management team, recognize that all failure is caused by people, and that all people learn in retrospect. We also recognize that we will all, at one time or another, be

part of the problems we experience (ourselves included).

Knowing this, we require that all people that are involved in undesirable events be considered “stakeholders” of these events. All stakeholders will be required to try to see

themselves as part of the problem, as well as required to state what they intend to do about their admitted role. No-one will be allowed to blame anyone for anything. Instead, all of us will be required to see our own roles. We consider personal introspection to be the ultimate in personal responsibility. We also consider this a condition of employment.

In return for your agreement and participation, the management of this organization promises that they will not punish you or anyone else as a result of being a stakeholder.

Administered by a strong causal

learning function at your site…

…with participation by all.

You don’t have to wait for someone else to make

this happen!

Anyone, anywhere, can start the change!

Lead by example!A leader can shape his

followers best by showing them the way forward rather than telling them about it………… Albert Schweitzer

If you want to make a change, be the best example of that change and others will follow………. Mahatma Gandhi

If you want others to do it, you have to do it first!

Operator TERMINATED!

Operations: Many of us have been sleeping at this particular control panel for years. It is not intentional! It is almost unavoidable. It’s usually one of the most boring assignments in the plant, especially at night.

Supervision: We knew that our operators were sleeping at the control panel, but we never did anything to correct it. Everyone knew. No-one did anything about it.

Supervision: We felt sorry for them. It is normally one of the most mundane jobs in the plant, so we purchased comfortable, reclining chairs to make their lives a bit easier.

Instrument techs: We disconnected the audible alarms that would have woken the operators. They kept tripping prematurely and we didn’t have time to troubleshoot them.

Area management: We had no idea any of this was occurring right under our noses. We are consumed in meetings that we ourselves have been arranging, rather than being dedicated to helping our people.

Operator TERMINATED!

Everyone wants to change the world, but no-one wants to change

themselves…..

Leo Tolstoy, 1828-1910 (Russian author and philosopher)

Thank you for your attention.C. Robert NelmsFailsafe Network, Inc.

Documents

And its antidote C. Robert (Bob) Nelms Failsafe Network, Inc