Happy Holidays

I will be on hiatus the last two weeks this year.

Unfortunately, there will be no posts on my blog site until 04 January.



Until then, I wish you a warm and happy holiday season, filled with joy for you and those you love.

All the best.

Douglas E Dawson

Draining The Pond

My father-in-law owns a farm in Preston, Idaho (famous for the film, “Napoleon Dynamite”). There is a small creek (pronounced “crick” in Preston) that intersects the property and feeds a small pond in the center of the property. The story is sometimes told of when the pond had to be drained.

It seems there was some obstruction to the pond effluent. The pond had a small concrete dam with a steel plate flood gate. The flood gate was opened and the pond drained so the obstruction could be removed. As the pond drained, an old rusty Model A Ford began to appear. Once the water level passed the Ford, and as the pond continued to drain, an old refrigerator was seen. After the pond was completely drained, the Ford, refrigerator and other junk in the bottom of the pond were chained to the tractor and pulled out. The pond was then refilled.

Not long ago, I got the opportunity to drain the pond at work. I was assigned an investigation, the purpose of which was to find why we were not able to correctly account for some units of very expensive product. As I pursued the investigation, it was discovered that the operators had just a few seconds to count over one hundred units of product and that this was done about every 2-3 minutes. The counter measure was to create a template, that would be placed over a tray (or case) of units, to see if they looked correct. Voila! Problem solved.

What?! But, wait a minute! You say that there is still a problem with the accountability? Yep, you guessed it. I was assigned another investigation for the same thing not long after the first investigation. So I dug a little deeper this time. The data I analyzed showed that the templates for counting the units of product worked well on the large units, but because the small units were in presentations of nearly 600 units, it was difficult for operators to tell if the count was correct or not. Hence, the potential for an erroneous count was still there. The counter measure implemented at that point was the introduction of an automated visions system that would use a computer and camera to do the counting, taking out the potential for Human Error. Finally! Glad that’s over.

Hold on now! I just got done fixing this problem. It can’t still be happening, can it? Another investigation assigned for the same thing, yet a few weeks later. When will the bleeding stop? In this investigation, I learned there was a new step in the process for additional testing to ensure oxygen content of the product was less than 1%. Final unit accountability of the product was completed before this step was executed. The problem was that a failed unit would be rejected, thus changing the count. This was not accounted for in the planning phase for implementation of this new step in the process; fixed yet again.

Process improvement is often referred to as Draining The Pond. It is the process of looking for incremental improvement rather than betting on big step changes. As you improve productivity through process improvement, you find other opportunities for improvement. The beauty of Fault Tree Analysis, is that you can capture several gaps in the process – junk in the pond – simultaneously by creating a visual of all the hypothetical gaps.

When I was doing these investigations, I was not disciplined in using Fault Tree Analysis in this way, but it would have helped prevent the non-value added activity of doing multiple investigations for the same issue. That is not to say that Fault Tree Analysis will be the end all, be all for any issue. I have been involved in investigations that used Fault Tree Analysis, which did not capture all the potential gaps for the Loss Event. However, capturing more gaps in an investigation, rather than fewer, is a more efficient way of…

Draining The Pond.

Perfect Execution or The Perfect Plan

I read a white paper some years ago, published by a well known global consulting firm, which stated something similar. The hypothesis, which was successfully argued, was that, "Perfect Execution delivers better results than a Perfect Plan."

The fundamental process for Lean Six Sigma (LSS) is DMAIC - Define, Measure, Analyze, Improve and Control. The essence of the American Express article is that, in corporate America, we sometimes get bogged down in the Analyze phase of any launch or implementation. We sometimes feel we need to know the minutiae of detail before we feel comfortable taking the risk of launch/implementation.

The fact is, that without risk, there is no reward. Referring again to LSS methodology, being risk averse completely bypasses the Improve phase of the DMAIC process. Beta testing, used by the IT industry, is in essence, a Pilot Project - something that is often used in the Improve phase of DMAIC. The purpose of pilot testing is to gather information not available by any other means. In other words, you are launching/implementing without all the data you need.

Collection of the data gathered by the pilot/beta test, allows you to tweak your process/product so that you can Control (read as "sustain") results and at some future date, Validate (another key component of the LSS methodology) the process/product.

Given this argument, it is far more important that the pilot/beta testing, be executed flawlessly. Execution is the most critical factor. Disciplined execution will provide all the data that is needed and much that was unexpected and which can also be used. It also places trust in the end user of the product or process, which gives them "skin in the game." This kind of leverage drives both the success and sustainability of the implementation/launch.

When doing investigations, which often use LSS tools (Fault Tree Analysis), it is far better to execute robust Root Cause Analysis, and appropriate Counter Measures, than it is to try and find every little reason why the Loss Event occurred. This approach (the perfect plan) can soon become counter productive. I'll share more on this in a later post about Draining The Pond. In the meantime, think about what will get you the results you desire...

Perfect Execution or The Perfect Plan.

A Writer Writes!

I have a favorite movie. It is a dark comedy starring Billy Crystal, who plays Larry, a bitter and frustrated would be author, teaching creative writing at the local community college. The movie is a hilarious dark comedy, but that's not the point of this post! At the end of each class session portrayed in the film, Larry finishes his class session by stating to his students, "A writer writes!"

I am currently in the process of studying a book. I say studying because at first I just read it. The book is entitled, "How To Run Seminars & Workshops," (Robert L. Jolles, Wiley, ISBN 0471715875). There is a section on writing, which states, "Planning to write is not writing. Thinking about writing is not writing. Talking about writing is not writing. Researching to write, outlining to write - none of this is writing. Writing is writing."

So now I have two paragraphs in this post about writing. Why, one might suppose, is that? Well here it is: You can execute an Investigation. You can do it using Fault Tree Analysis or some other methodology. You can identify Root Cause and the appropriate Actions to mitigate the Loss Event and prevent it's recurrence. You can involve SMEs and your Investigative Team members. At the end of the day, you will have to document your findings. For many people, this is sometimes the worst possible aspect of an investigation, made more so when the summary requires approval from various parties, each of whom has their own opinion as to style and grammer, and which can reject your summary for tawdry edits that often don't make sense.

There are a million reasons why we don't like to write. However, at the end of the day, if we do not write at one point or another, the investigation is incomplete. In order to truly complete the investigation, it needs to be "wrapped up in a bow," through documenting (read as "writing") the investigation.

Lead Investigators, or at least a member of the Investigative Team, is typically a writer. And the Root Cause Analysis, must be documented and summarized so a record exists for review in the future. If for nothing else, to enable prevention of the same issues in the future. You may not feel like your documentation is up to par, and perhaps it is not. At least not now. But the more you write, the better you get at writing.

Over the course of a 26 month period, I documented 115 Investigations, all requiring full Root Cause Analysis. Many suggest that I am an expert. However, I contend, if that is the case, it is only through the continued practice that took place from writing so many investigative summaries in so short a period of time. Anyone can develop this skill set if they have a mind to. It's not difficult, although you have to toughen up your hide and accept feedback from time to time. But this is no problem if you truly wish to excel. The key thing to remember is...

A writer writes!

Could You Please Show Me Your ID?

The organization I work for requires an ID card to enter the network of buildings that make up our campus. I am a person of routine. My wife often refers to it as OCD, but I prefer to think of it as routine. To some degree, we are creatures of habit.

At any rate, on this particular morning, my commuter vehicle was in the garage for maintenance, so I had to drive another vehicle. I forgot to transfer my parking pass from the commuter vehicle to the one I was temporarily using. I had to stop at the front gate and ask for a temporary parking pass.

"Could you please show me your ID?" the security guard politely asked.

"Sure, hang on a minute," was my reply as I started digging my wallet out of my back pocket. No sooner had begun search for my wallet, that I became painfully aware that my morning routine had somehow been disrupted and I had left my wallet on my dresser. I commute an hour each way and I plead with the guard, now somewhat suspicious, that I for me to run back home for my wallet, would constitute and additional two hours of drive time for me, and two hours of lost productivity for the organization.

Suspicion had evolved to impatient indifference and I was waved on to the security desk at the main entrance. Once I got there, it took nearly an hour to get through all the red tape that would allow me to get to my desk and grind out value for the organization. But I made it. Finally.

What does this have to do with investigations? As you build your Fault Tree Analysis, you need to give each hypothetical cause in your growing tree a value. This value is called a Fault ID. The Fault ID helps investigative team members, approvers and stakeholders understand the relationships of the various faults hypothesized to be potential root cause, as well as potential relationships they may have one with another.

Top line, or First Order hypotheses have a value represented as a whole number beginning with zero or one and progressing from there. Secondary or Second Order hypotheses have a decimal value of one place, such that any hypothesis subordinate to a First Order hypothesis would be as 1.1 for the first hypothesis, 1.2 for the second and so on. Tertiary, or Third Order hypotheses are separated by decimal as a delimeter and follow the same convention as the Second Order hypotheses. In other words, Fault ID subordinate hypotheses to Fault ID 1.1 above, would be 1.1.1, for the first tertiary hypothesis, 1.1.2 for the second tertiary hypothesis, and so forth. This convention is true also for Quaternary and Quinary subordinate hypotheses.

For an example of a partial Fault Tree showing Fault IDs, look at the image below.

When you think of order of magnitude, as you build your Fault Tree, it can become very large and quite cumbersome. This is where the Fault IDs of the various hypotheses becomes most important. Keeping track of these hypotheses, and seeing the potential Interactions that exist are key a successful investigation. Particularly if it is a large scale investigation.

The Fault ID has additional value I'll save for a later post. The point of this post is to explain what, exactly, a Fault ID is and how it is used. Below, you can see an image of what a Fault ID looks like. Just remember that when you are building your Fault Tree Analysis, someone interested in your investigation, perhaps an Investigative Team member, a Stakeholder or an Approver, may ask you...

Could you please show me your ID?

Were You Entitled, or Was The Title Won?

NOTE: The title of this post is also a link to the article referenced within the post.

I recently received a post (see link above) regarding "Learned Helplessness", which is defined as "where people 'learned to behave helplessly, even when the opportunity is restored for them to help them self by avoiding an unpleasant or harmful circumstance.'" Unfortunately, I see "Learned Helplessness" too much in business and community. I believe our culture has evolved from the independent self-sufficiency exemplified by the puritanical contingent of our country's forefathers, to a culture of entitlement (read as "helpless").

I work with and teach others to take ownership for who they are and the results of their actions. This is often times difficult when people have been entitled too long, but told they are performing well (read as "vanilla" not "balanced" feedback) in spite of the evidence of their labors. I have a 2X2 Capability Awareness matrix I use to help illustrate the entitlement mindset. It is sometimes difficult for people to accept, but once they do, they are on the road to recovery.

Ultimately, the fundamental flaws of our economy right now are evidence of this mentality. Unfortunately, it does not just evidence itself with the "less fortunate." Learned Helplessness is often enabled in the executive suites, by group think, or what I like to refer to as Cognitive Myopathy. At other times it is enabled by lack of integrity and professional courage.

In short, Learned Helplessness has pervaded every facet of our society in pandemic proportions. Sounds pessimistic doesn't it? I, however, am an optimist. I believe that armed with the correct knowledge, delivered by those with the professional courage to render the appropriate balanced feedback, that most people will want to do the right thing and to feel good about, rather than justify themselves. Given this assumption, I believe also that ours is not a hopeless state. As stated in my prior post, good investigators are generally also good leaders. They have to leverage leadership to gather, assimilate, collate and make sense of all the data that exists around the Loss Event and then identify and develop Actions for the Root Cause. If you are doing investigations, and not exemplifying the characteristics of a good leader, you are in danger of a less than complete investigation. In order to accomplish a good investigation, you have to work at leadership, and as such, solicit the help and support of other. An attitude of Entitlement or Helplessness, will only scare of the support you need to be successful.
So when you are done with the investigation, ask yourself...Were you entitled, or was the title won?

Does That Include Me?

NOTE: The title of this post is also a link to the article referenced within the post.

Good investigators are great leaders. They have to be. I've just only begun to realize how true that is. Attached to this post is a link to an article I recently read in a magazine I subscribe to. The article, entitled, "How To Build Great Leaders," discussed the value of developmental assignments as one of the tools that are used by organizations to build great leaders. My organization is on the list of the top 25 cited in the article. I have a colleague who has gone to Harvard Business School as a developmental assignment. I have several other colleagues who have been assigned overseas for three years for leadership development.

As I read through the article, I began to wonder why I was not getting some of these opportunities. And then I began to think about what I am doing for the organization now, and how I got there. But first, allow me to back up.

According to the article, developmental assignments are costly in that you leave a role in which you are being productive (read as adding value to the organization) and are assigned a role in which you are not necessarily being productive (read as learning or developing). In the latter case, a return on investment for the developmental assignment may not be realized for years after the assignment. Many times, these developmental assignments are grueling in terms of demand on time and other personal resources, because you have to really push the learning curve to keep up.

As stated above, I began to wonder why I was not getting some of these opportunities, but stopped short when I thought about what it was I was I am doing for my organization now and how I got here. Prior to my former role, I had been given a challenging leadership position (formal) at which I had been successful. I had asked specifically about further developing my leadership skills and was placed in an individual contributor role, the purpose of which was to focus on improvement of the process I would be supporting. I was in this role only six months before it became apparent that there were going to be numerous manufacturing deviations for some time to come. Although I had a team of peers I worked with, the responsibility of investigating and resolving these deviations fell to me.

In January of 2007, the organization implemented a new database for investigating deviations and storing all the details of each investigation. This system has queries that will enable anyone to identify how many investigations they have actually done. From 01 JAN 2007 to 01 MAR 2009, slightly over two years, I had performed 115 investigations requiring full Root Cause Analysis and supported several others. It was challenging and difficult. I often viewed myself as not much more than a technical writer. My focus got more narrow as time went on, such that all I was doing was these investigations. Long hours were put in to manage a nearly unbearable workload.

I was informed in NOV 2008, that I would soon have a new role and in MAR 2009, took the role I now have as a member of a team of individuals specifically tasked to investigate certain types of deviations called trends. We use Six Sigma tools (I'm a Green Belt) and other investigative techniques and impact is sometimes beyond the site I support. We are an eclectic bunch and have learned to work well together. We are just now preparing a year end presentation of our results for senior stakeholders.

How, you ask, does this relate to the article cited above? First of all, allow me to explain that there are formal leaders and there are informal leaders. Formal leaders have titles stating them as such. Informal leaders do not. Not everyone can be a Formal Leader. There is just not enough opportunities to go around. In any organization. Some people are Formal Leaders due to skill, talent, nepotism, favoritism, timing or any combination of these. Some are controllable, some are not.

On the other hand, everyone can be an informal leader. Allow me to repeat that one more time: EVERYONE CAN BE AN INFORMAL LEADER. Given this fact, then the equation for leadership changes a bit. I left a role as a Formal Leader to work for a time as an individual contributor. I was not able to utilize my skill set in the manner described in my job description, nor to my own personal expectation. I felt that I had left a role where I was productive. In my new role, I was productive, but not in a way I felt good about at the time.

After three years, and a lot of frustration, I was assigned my current role, also as an individual contributor. Admittedly, I was somewhat frustrated coming into this role, but then the clouds parted and angels began to sing. The work I had done over the previous three years, although unexpectedly, had helped me develop a skill set highly valued by the organization. My networking, investigative, communication and yes, leadership skills, had all improved significantly. This was not overt. I did not realize this until things started developing as I settled into this new role.

This was a significant learning for me. So when you hear about the fancy assignments overseas or at Harvard or MIT or whatever, perhaps you can step back and take a look at what you are doing right now and ask: Is what I am doing a developmental assignment in disguise? What can I learn from this role, frustrating as it may be, that will position me to be a better leader, formal or informal, in the future.

I believe that when things are painful, we are either growing, or missing a significant opportunity to grow. When things are easy, we are not challenged and when we are not challenged, we do not learn. If we don't learn, we may be cutting ourselves short on future opportunities. If you accept this as fact, then after you read the article above on organizations that build great leaders, and then ask yourself, "Does that include me?" The only answer is...

...YES!!!

Descend To The Lowest Level You Can!

How often have you overheard a conversation and heard the phrase, "I don't think they can get much lower than that." Usually, this is about someone in particular and their perceived behaviors. The statement generally has a negative connotation.

How about the sometimes wildly entertaining Caribbean dance, the Limbo? The object is for participants to dance under a bar or pole, that is lowered through successive turns of the participants. When a participant falls, they are eliminated from the dance, until the dancer who can go the lowest remains. The thought is, how low can you go?

When doing an investigation, you want to get to the lowest level you can. You want to peel away the layers of circumstances that will get you to the root cause. This is often done using "Cause of the Cause" or "5 Why Analysis". Fault Tree Analysis is a disciplined approach to these processes. Essentially, you want to go as low as you can go. You want to descend the lowest level possible.

Each hypothetical cause has one or more hypothetical causes subordinate to it. Eventually, you will get to a point where you have exhausted all reasonable possibilities. Typically, you will find that there are usually no more than five levels of "Why" or hypothetical causes. Evaluation of these hypothetical causes then lends you some measure of confidence as to whether they were truly contributory to the Loss Event. The key, however, is to go to the bottom, get to the root of the Fault Tree, or the Root Cause.

When pursuing your investigation, it is important to remember...

Descend to the lowest level you can!

To Be or Not To Be...

Hypotheses are interesting things. They are, or they are not. There is no middle ground. Now on the other hand, you may have some measure of confidence (which we will discuss in a later post) as to whether the hypothesis is, or is not. When pursuing an investigation, you are inundated with hypotheses.

What are hypotheses, relative to an investigation? Well, once you know what the Loss Event is, you have to hypothesize different scenarios that might have caused the loss event. Some of those hypotheses will be the result of data that you collect immediately after the event and when you build your time line. Others will be what if's based on SME knowledge of the process surrounding the Loss Event. Others still, will be subordinate to the first level hypotheses. In other words, cause of the cause.

Ultimately, what you wind up with is a Fault Tree of hypotheses. You will begin collecting data that will enable you to prove your hypotheses with some measure of confidence. As you work through all the hypotheses in your fault tree, you will eventually begin to discern either Root Cause, or one or more interactions leading to the Loss Event. In the end, a Fault Tree is a grouping of hypotheses either related and/or subordinate to one another, and which lead to the Loss Event.

With respect to the truth of any hypothesis found on a Fault Tree:

To be or not to be...

That is the question!

Do It, Do It Right, Do It Right Now!

Last week I had a posting called, "Just Do It!" after the Nike slogan, used so often in their advertising. Before, "Just Do It!" was even considered by Nike, I was serving a mission for my church in the late 70's. One of our church leaders had a placard on his desk which said, "Do it, Do it right, Do it right now!" Everyone knew that this was his credo and we made it ours. It has since stuck with me.

So what does the mantra, "Do it, Do it right, Do it right now!" have to do with investigations? The following are my thoughts on the matter:

1. Do It: This simply means "Take Action." If no action is taken, nothing gets done. A Loss Event has occurred. You are aware of it, or previously unaware of the Loss Event, it has been assigned to you for investigation. Take Action. Begin the investigation. Understand the events surrounding the Loss Event and use that understanding to determine Root Cause. The point is, that unless you "Do It," nothing will ever be resolved. No Root Cause will be found.
   
2. Do It Right: When taking action, during the course of your investigation, be sure you are taking the right action. Question everything. Require the appropriate data to support or disclaim all your hypotheses. Talk to the SME's and SMI's, both. Don't be afraid to challenge. Don't be afraid to be challenged. Gather all the data and information you can. Organize it, codify it and prepare it for review and/or approval. Most of all, be sure your Corrective Actions are appropriate and sound and prevent future Loss Events of like kind.
3. Do It Right Now: There is a sense of urgency in business. Any business. The business of work, the business of community, the business of family, all require some sense of urgency to resolve issues and resolve them quickly. Understanding this as investigators, we should take action and we should take the right action. However, waiting does not help at all, we need to take action now! The sooner we take action, the sooner resolution will take place, the sooner we improve whatever process we are investigating, and the sooner we reap the benefits of such.

Life is full of challenges and choices. These are compressed even further in the traditional business environment. Investigators are leveraged to understand why some of those challenges occur and how to prevent their recurrence in the future.

When you are faced with the challenges and choices of life, in your work or otherwise, as an investigator, just remember...

Do it, Do it Right, Do it right now!

Big D, little d, what begins with d?

When I was very young, (according to my son, when dinosaurs roamed the earth), I had a book entitled, "Dr. Seuss's ABC: An Amazing Alphabet Book!" It was one of my most favorite books and I remember the silly animals and items Dr. Seuss created to make an impression as to each letter of the alphabet.

Each alphabet character started with a new page and a new phrase. Something like this: "Big A, little a, what begins with A? Aunt Annie's alligator, A...a...A!" And so it went through the entire alphabet. It was silly, as only Dr. Seuss can be. It was hugely entertaining and somehow, learning surreptitiously insinuated itself amongst all the mirth and fun. Little did I realize, at such a tender age, my career in business would find another meaning for the phrase "Big D, little d, what begins with d?"

Some years later, (read 'a lot of years'), I was employed by a Fortune 500 company (not the one I am engaged with now), and they discussed the value of diversity as a means for competitive advantage. This organization divided diversity into two distinct groups: Big D and little d. The Big D represented protected classes. Those things, which to most of us, are obvious: Race, Creed, Color, Gender, Religion, etc. The little d represented those things which were not so obvious: Where you were raised (Midwest or Rocky Mountain West, urban or rural), where you went to school (Utah State University or Harvard, Trade School or higher education, high school or college degree), what you do with your spare time (watch TV or read a book, race a car or race to the store).

This organization taught and I personally agree with, the idea that the true value of diversity is getting past the Big D. That is not to say that the Big D is not important; it is. But that is like saying a wedding cake is important. Everyone at the wedding can see it and knows it's there. You can't really have a wedding without one. Comments abound on how it looks, the delicate floral frosting, the subtle colors and so forth. When people really get interested in the wedding cake is when it is cut. Does it have filling or not? If so, what kind of filling is it? Is it a white cake, yellow cake, chocolate cake, spice cake or some combination in layers? That's when the wedding crowd starts making the decision to take action on how big and how often they will have a piece of cake.

Diversity is the same. We need to get beyond the obvious. Doing so allows us to see what the real competitive advantages are. Reference my blog post about the IDEO company, (as well as any blog posts with the label "Diversity".) Any way, the IDEO company: they leveraged the little d and got fantastic results in what is now known as the shopping cart project. Investigative teams are the same way. It is the little d that truly delivers results.

The problem is that it is difficult and challenging to try and find the little d and what value it will have on the Investigation and the Investigative Team. Doing so requires discipline and forethought. Lead Investigators that exercise this type of deliberation, will have much more robust investigations. The risk of not understanding and leveraging the little d is Cognitive Myopathy.

So...Big D, little d, what begins with d?

A good, robust Investigation!

Root Cause Investigation of the Month Winner

On my pager, I was just sent a page from a colleague (not more colleagues!?) to look at my email account at work. When I did, I was surprised to find that I had been selected, in my Corporate Division, as the Root Cause Investigation of the Month Winner. What I was even more gratified by, was that the things that I think are truly important to a good Root Cause Analysis, were all listed as components of the selection criteria.

The body of the text in the announcement included the following:

"Strong points include: 1) Performed thorough fault tree analysis of the situation and provided data for those paths both pursued and eliminated, even though confirmed root cause could not be identified, 2) Employed investigative tasks to obtain SME contributions, 3) Supplied solid data to support impact conclusions and final disposition, 4) Employed good technical writing practices, and 5) Demonstrated adherence to [appropriate] tools. In addition, the [investigative] team exhibited curiosity and open-mindedness."

My intent in sharing this is not to toot my horn, so much as to illustrate that development of this skill set is highly valued by organizations. There are not a great many individuals that are willing to do what it takes to seriously develop these skills. Doing so requires you to make yourself vulnerable by soliciting feedback, and credible, by acting on that feedback. Demonstrating these behaviors with each investigation will drive improvement of your skill set, as well as your capability within the organization.

The Root Cause Investigation of the Month Winner is...

[Insert your name here]

Just do it!

Years ago, before I had written my first book, I saw a movie entitled, "Throw Mama From The Train." The film starred Billy Crystal. Crystal's character was an instructor at a community college teaching creative writing. At the end of his classes, he would close the session with the line, "...and remember, a writer writes."

Not long ago, I had opportunity to read a book entitled, "How to Run Seminars & Workshops: Presentation Skills for Consultants, Trainers and Teachers." I read a comment in the book, that paraphrased, stated that outlining is not writing, talking about writing is not writing, only writing is writing. This holds true for investigators in two different ways.

First, an investigator cannot complete an investigation without the appropriate activity taking place. An investigator, investigates. It doesn't matter if you are a Six Sigma Green Belt or Black Belt, an investigator using Root Cause Analysis, or any other methodology. Nothing happens until you start investigating.

Second, an investigator writes. all the investigation in the world is meaningless for others to learn from, unless, the investigation, and the results of the investigation are documented. Furthermore, many organizations require approval of the investigation from many different functions, as well as different layers of management in the organizational structure, requiring a technical document describing the investigation and it's results. An investigator writes.

What does one do if they don't really like to write? An investigator, investigates. An investigator writes. To quote a Nike ad that will be easily remembered...

"Just do it!"

Johnny Appleseed and Fault Tree Analysis

As a child in the sixties (as opposed to a child of the sixties, if you know what I mean), I learned about an American folk hero, part legend, part reality, named Johnny Appleseed. He would travel the frontier, what we now call the Midwest, planting apple trees. Little did I know, that later in my adult life, I would venture to and settle down in, the literal stomping ground of this icon of American folk lore.

Born John Chapman, Johnny Appleseed was an American pioneer nurseryman who introduced apple trees to large parts of Ohio, Indiana, and Illinois. He became an American legend while still alive, largely because of his kind and generous ways, his great leadership in conservation, and the symbolic importance of apples.

What does Johnny Appleseed have to do with Fault Tree Analysis? Well, I thought you would never ask. And if you didn't, I'm going to tell you anyway! Johnny planted apple seeds and they grew up into trees. As investigators, we get loss events planted on us, but that's OK, cause that's what we do. Our Fault Trees grow down into trees, much like a root system.

1. You start with the Loss Event.
2. From the Loss Event, you identify Causal Factors. These may be locations in a value chain, or activities on a time line. Either way, Causal Factors are high level hypotheses as to the occurrence of the Loss Event.
3. From the Causal Factors, you identify the Root Cause Categories. These are hypotheses subordinate to each of the Causal Factors. You can begin to see how this tree grows.
4. From Root Cause Categories, you then have your Near Root Cause(s), which are further hypotheses as to the Loss Event, subordinate to the Root Cause Categories. Now you're really drilling down.
5. Finally, from the Near Root Cause(s), you derive Root Cause(s). These are subordinate, still, to the Near Root Cause(s). They are still hypothetical, until validated otherwise through qualitative and/or quantitative data. (This process is the Verification Log, which I will discuss in another post.)

As you can see, the Fault Tree has now grown and you have the makings of a robust investigation on your hands. (For an example of a simple Fault Tree, you can click on the image below.)




Hmmm....

Perhaps Johnny Appleseed could have benefited from using Fault Tree Analysis to determine why apple trees and conservation were lacking in the Midwest at the time, rather than plodding around the country side.

Just a thought.

When The Lead Investigator Is Happy...

Yesterday, I was speaking with yet again, another colleague (I have a lot of colleagues!), and shared with her (we'll call her Christine, her real name is Christine), this concept of SMIs. Although I found the term intriguing myself, Christine really enjoyed it and was quite animated. Here, I believe, is why:

1. If you acknowledge someone as an SMI, and you bring them into the investigative team as an SMI and if they embrace the idea of being an SMI, this has great potential to bring an air of fun and light-heartedness to the investigation. In my view, a sense of fun, makes what would otherwise be a tedious investigation, go much faster and more interesting.
2. If the SMI understands clearly their role as such, then they will have the added value of being consciously critical, asking the difficult why's without fear or reservation.
3. If the SMI is comfortable and has fun with their role on the investigative team, then you have clearly established a safe environment for the investigation to take place in.

Actually, all these points are indicative of a safe environment. Christine's animation about the SMI concept, is because she holds these three things in high esteem. She knows the value of a safe environment for an investigation, especially a difficult one.

One of the single most important aspects of an investigation, is that the environment IS safe for all the investigative team members. This allows for a forum where anyone can speak wit hout fear of judgment or repercussions outside the investigation. Especially SMIs. When team members can operate without fear, then ideas and interaction flow freely, accelerating the investigation.

This makes the Lead Investigator very happy. And you know what they say:

When the Lead Investigator is happy, everyone is happy!

(By the way. Today is my son's 20th birthday. He is in Spain and I haven't seen him since February 18th. So here is my message to him: ¡Cumpleaños felices Lorin Douglas! )

Subject Matter Idiots

I was in yet another conversation, with yet another colleague, as we discussed the value of having someone who is not close to the process, to be on the investigative team. He is a Six Sigma Black Belt and told me that his group called these people SMIs. Like a goof, I asked what an SMI was and he responded, "Subject Matter Idiots."

We had a good laugh, but his point is well made. You want someone who knows nothing about the process being investigated. They are not afraid to ask questions that won't be asked by people who, because of their expertise, may not consider the question at all. Not because they are above the question, but because they are too close to the process, for the question to even be on their radar screen.

I like to think of this concept as a painting by Claude Monet, credited with starting the "Impressionist" era in art during the late 19th century. Monet used textured "dobs" of paint to create an impression of what was seen by the observer of the painting. Consider his work, "Sunflowers", a famous still of sunflowers in a vase on a table. If you were to get as close at this work as you physically could and look at it, all you would see were "dobs" of oil paint in rich yellows and oranges, with some greens, which made no apparent sense at all. But as you stand back, you can see the collection of color swaths come together to make sense of something meaningful to the eye of the observer.

Investigations are similar. Subject Matter Experts (SMEs) are too close to the process. Whereas an SME cannot see the broader view because of their Cognitive Myopathy, an SMI has no Cognitive Myopathy. Without such a filter, there are no rules and anything, or any question, is fair game.

I have been involved with investigations where SMIs took the investigation down the path to true Root Cause by asking the "why" questions no one else could see.

When you need a fresh perspective, don't be afraid to leverage a Subject Matter Idiot.

More On Congnitive Myopathy

I was in a conversation with a colleague recently. We were discussing the importance of Group Think and how to avoid it during investigations. As we talked I had an epiphany: Group Think, Tunnel Vision and Myopic thinking can be distilled down to one term, which is Cognitive Myothapy. (I just did a quick Google search and the term "cognitive myopia" already exists, so I am going to lay claim to Congitive Myopathy, caps and all!)

At any rate, during this discussion I referred to, my colleague shared with me his thoughts on Cognitive Myopathy. He decided that every time he runs an investigation, he tells everyone to check their old paradigms at the door. He also said, if they insist on sticking with their old paradigms, that he requires them to produce the data to prove those paradigms correct. He gave an example of a massive investigation he was involved with.

Let's call my colleague "Kris" (that's actually his real name). He had a group of engineers, scientists and operations people trying to find the root cause of the Loss Event that had occurred. There was a great deal of equipment involved. Each piece of equipment had an "owner" responsible for it. As the group was building the Fault Tree and certain pieces of equipment came up as hypothetically contributing to the Loss Event, there were vehement denials. Kris would simply tell the equipment owner(s) that he had no problem with their assertions, but that he would include that equipment on the Fault Tree until data had been produced to support those assertions. Clever, eh?

I thought this was a masterful way to get the equipment hypothesis on the Fault Tree without having a blood letting take place. Once on the Fault Tree, you don't ever take off the hypothesis, you just upgrade, or downgrade the Confidence Rating or Fault Value (read as probability), assigned to it. No harm, no foul.

Kris is a great investigator, but I believe he is even better at facilitating difficult investigations. Doing so requires that the facilitator know how to recognize the potential for, and manage Cognitive Myopathy. I thought this was one of the most diplomatic ways to handle a difficult situation regarding an entrenched paradigm I had ever heard of. I'm going to use it myself.

So just remember, if you choose to ignore the potential for Cognitive Myopathy to creep into your investigations...

...Let the blood letting begin!

Group Think is Thoughtless

In the 18th Century, the Vienna General Hospital had a serious problem. There was a high degree of infant deaths due to puerperal fever. Data for infant deaths became available in 1784. From 1784 to 1822 the infant mortality rate was about 2%. From 1823 to 1841 infant mortality was about 7% and from 1841 to 1846 it jumped yet again to nearly 10%.

Women plead not to be admitted unless they had to be, knowing their babies had just as good a chance at survival, outside the hospital as in. Physicians studied this phenomenon and could come up with no cause as to why. Doubly perplexing was that infants delivered by mid-wives had a mortality rate of 0.6% as opposed to the infants delivered by the physicians and medical students, which had the near 10% mortality rate.

In 1846 Dr. Ignaz Semmelweis agreed to a three year contract to work at the hospital, beginning that year. He became aware of the problem, pored over the data and learned that in 1823, pathological anatomy began at the medical school, where physicians and medical students would dissect and study cadavers. Midwives did not attend the medical school, and as such performed no pathological anatomy. The physicians and medical students would complete their anatomy classes and then attend to the obstetrics of the hospital, now being carriers of cadaverous contamination.

Upon recognizing this issue, Semmelweiz instituted the practice of hand washing in chlorine after a physician or medical student completed a pathological anatomy. This was instituted in 1847. Infant mortality rates from 1847 to 1858 were about 1.6%, significantly lower than the nearly 10% mortality rate before.

During the decades prior to the investigation of Semmelweiz, the physicians in the hospital could not begin to fathom that anything they were doing would be the cause of the increased infant mortality rates. This is a classic example of Group Think. Group Think is found in organizations (larger than one individual). Tunnel vision and myopathy are synonymous with group think, but can also apply to the individual.

I read a book once, entitled, "Leadership and Self-Deception: Getting Out of the Box," in which the example was given of an infant learning to crawl. The infant gets up on its hands and scoots around by pushing itself back. Eventually, it gets wedged against something and cannot scoot back farther, becoming trapped. Frustrated, it screams and cries and pushes back harder, but to no avail. The paradigm of the infant does not allow it to consider that it might be the source of its own problem. If it could see the problem, it may not be able to do anything, if much about it, because it may not have the capability to change direction without pushing back. Intervention is nearly always required.

This is the hallmark of Group Think, Tunnel Vision and Myopic thinking. That is why it is important to have the emotional maturity to allow someone else to challenge the thought processes we are engaged in. This is critical to a good investigation. Having someone on your investigative team who will challenge the process can get others to see and think about things in a different way. This is necessary to a robust and successful investigation.

Group Think is thoughtless.

Loss Events & Losers

Nobody wants to be a loser. In order to not be a loser, an organization must understand what a Loss Event is. Understanding what a Loss Event is, will enable the organization to investigate the cause of the Loss Event, identify Root Cause, and the appropriate Action or Counter Measure(s) to correct the Root Cause. However, before any of this can happen, the organization must understand what a Loss Event is.

Simply put, a Loss Event, is where something is lost in the process of doing business. I don't necessarily mean the type of loss that would prompt you to go to the lost and found. Rather, the loss is typically measurable in monetary terms, for most businesses. Losses can be the dollar value of down time, defects, a safety incident; you can think of as many examples as there are companies in operation.

The problem is, that any loss event represents lost revenue to the organization. If the loss event is down time, then you have the cost of not producing product, the cost of replacing equipment that was damaged or in disrepair, the cost of labor during the downtime, etc. If the loss event is defects, then you might have the the cost of rework, lost opportunity cost if you cannot rework and have to scrap, cost of equipment or line time to do the rework, cost of overtime to execute the rework or manufacture replacement product, etc. If the loss event is a safety incident, you can follow nearly all the same paths for the cost involved, but you might have some different costs such as doctor's visits, workers compensation, etc.

The point is, that a loss event, in the simplest terms a business can understand, is the erosion of revenue and/or profits. In order to understand the cause of the loss events, organizations will employ formal Root Cause Analysis (RCA). I personally like to use a Fault Tree when doing RCA. Using RCA methodologies will drive the investigator to Root Cause. Knowing Root Cause will enable the appropriate Actions or Counter Measures. The appropriate Actions or Counter Measures will prevent the Loss Event from occurring again. Prevention of another, similar Loss Event provides an incremental increase in the revenue and profits of the organization.

Organizations that have not figured this out, or choose to ignore Loss Events, are Losers, (fiscally of course!)

Ooops!! I could have had a...

I enjoy doing meaningful, robust investigations that really get to the root of the matter. They allow me to be involved in improving whatever process is impacted. This is something I find a great deal of satisfaction in.

The other day, I asked for feedback on a presentation I was giving for approval of an investigation I am working on. The investigation was not one of the type I had done before, was exceptionally high profile and had a very compressed time line for the level of effort and detail that would be required. I was given some reference numbers, in our database, of similar investigations I could review, and perhaps use as a template for my investigation.

Well, I did just that and started digging in. However, I was so zoned on completing the investigation, that I missed one of the key fundamentals I usually adhere to; I failed to utilize Fault Tree Analysis as a means of getting to Root Cause. I am not a disciple of Fault Tree Analysis. I AM A ZEALOT!! And yet, I failed to do what I am normally quite disciplined about doing.

Back to my feedback on the presentation: I was asked, "Where is your Fault Tree Analysis?" After trying to justify myself, I gave up and capitulated to what I knew was the truth; I had buried my nose so deep in the template, that I failed to do a thorough investigation.

I was forced (by my own behaviors) to rework my work (terribly painful on a personal level) and build my Fault Tree. The end result of the investigation was no different, but the Fault Tree provided substance to what I had done with the template and made it easy for the approvers to see my conclusion and how I had gotten there. In the end, I was glad I had to rework my work. (That's kind of a catchy phrase!)

I've now put together a little checklist for me to follow, so that when I am steeped in a big investigation, I won't slap my forehead with the heel of my palm and say, "Oooops!! I could have had a...

...Fault Tree!

Leadership: Make or Buy?

I received feedback on my thoughts about the post entitled, "Investigators As Leaders" (Monday, 28 SEP 2009). It is possible that I may have unintentionally implied that some are born as leaders and that is what type of individual some organizations seek to hire.

For this I apologize. Leaders are both born and made. Some are born with a natural disposition toward leadership and quickly begin showing this natural talent as they grow up and engage with others. It is important to note that this does not dismiss such individuals from further developing their talent. Sports authorities are trained to quickly ascertain raw talent, and then to develop that raw talent.

History is filled with those who "should have been". I personally believe that there are few people in history that naturally rise in leadership capability because of raw talent. My belief is that the majority of those who demonstrate truly great leadership, did so because they had desire and heart: The desire to be good leaders and the heart to see it through. This is not easy to do.

The film "Miracle" (which I just reminded myself to add to my favorite movies on this blog), is a great metaphor for leadership. The coach of the Olympic U.S. Hockey Team portrayed in the film, did not go after the most talented hockey players of the day. It was not a dream team. He took players that had already demonstrated desire and heart and which had not necessarily "arrived" professionally in the sport. Once picked, he pushed his team hard, time and again, until they coalesced into a championship unit. He developed them.

Many companies choose to hire leadership skills and buy technical skills. Just as the coach in "Miracle" recruited people that had already demonstrated desire and heart, companies that hire for leadership do the same thing. It is incumbent on the candidates to prove to the company that they have been working to develop those skills. Furthermore, the development does not stop when the candidates pass through the doors on the first day of work. Companies that focus clearly on recruiting leadership, constantly challenge, develop, provide feedback, coach and opportunity so that leadership is further developed within the organization. Such organizations find it more cost effective to hire or "buy" resources that have already demonstrated desire and heart in developing leadership. The alternative of bringing someone in and to "make" them a leader is far more costly because of the unknowns; the risks involved.

Ultimately, the intent of message was that we should constantly be striving to develop our leadership skills. It matters little, in the big picture, if we are investigators, teachers, scientists, managers, etc. Leadership is essential to getting things done, effectively and efficiently; including investigations.

If I misdirected anyone on the intention of my thoughts, please accept my apology.

Bottoms Up!

There is a hierarchical structure to investigations. The key of any investigation is to get to the bottom of things, or rather, identify Root Cause. Until you get to the bottom of things, it is impossible to identify any real possibility to correct the issues causing the loss event and affect organizational improvement.

Key to identifying Root Cause and solving the problem is "cause of the cause" or "5 Why Analysis", both are very similar. Conceptually, you ask what the cause of the loss event was. Once you have a general idea, then you ask yourself what the cause of that was (cause of the cause) or why that happened (second layer in 5 Why Analysis), you continue to ask the same question, "Why did that happen?" until you can no longer go any further. Data suggests that you typically find Root Cause after asking "Why?" no more than 5 times.

Here are some hierarchical definitions that will help you in your investigations (it is important to note these are not original with me, and are generally considered standard in formal Root Cause Analysis):

1. Loss Event: This is the occurence of some event that caused a loss, of one sort or another, to the organization. e.g., machine failure, safety issue, suspect analytical result, etc.
2. Causal Factor: This is a generalization as to the cause of the loss event. Consider it the first "why" in 5 Why Analysis.
3. Root Cause Category: This is cause of the cause, or the second layer in 5 Why Analysis.
4. Near Root Cause: More cause of the cause and the third layer in 5 Why Analysis.
5. Root Cause: Cause of the cause and the fourth layer in 5 Why Analysis.

Fishbone diagrams and Fault Tree Analysis are good ways to get a graphical view of how things are shaping up. Build in a time line and you now have a two dimensional view of the loss event and all the factors impacting it.

Once you get to the BOTTOM of the loss event, you can finally serve UP some Corrective Actions that will drive organizational improvement.

Hence, Bottoms Up!

Time Lines & Tootsie Rolls

You ask yourself, "Tootsie Rolls?" A fair question indeed. Tootsie Rolls have nothing to do with time lines. However, time lines are not exciting and I needed to grab your attention as a result. Because time lines are not exciting many investigators either ignore or avoid them. The fact of the matter is that a time line is critical to the successful investigation of any loss event. Here is why:

1. A time line can help you identify all the activities that lead to the loss event. As you build the time line, you find gaps that you fill and you continue to build.
   
2. A time line can help you identify all the activities that transpired after the loss event. As you continue to build the time line, you find issues that obscured the loss event after it happened. These issues are important, as they also may represent gaps that need to be addressed.
3. Once your time line is constructed, you have an outline for your investigation.
4. A time line is extremely useful if your investigation requires approval, as it helps draw an organized picture of what activities or circumstances transpired around the loss event. (The key to approval is making it easy for the approver(s) to understand what happened.)
   

Nearly all investigations can be structured on a time line. Think for a moment of the press reporting an aircraft investigation. They are delivering news information about the aircraft accident, usually from a time line that the investigators have provided. This helps the press understand what happened. It also makes it easy for the press to convey to the public what happened. If your investigation has a time line outlined around the loss event, your written analysis will be smoother and make more sense.

So think about it; consider the value of a time line. If you've built them in your investigations in the past, continue building them. If not, start using them and see if they don't help your investigations immensely.

If you're not buying into the whole time line idea, it's time for you to get up and go get a Tootsie Roll!

Investigators as Leaders

When pursuing a large investigation, there are two skill sets required to see it through successfully to Root Cause. First are Leadership Skills and Technical Skills follow. This entry is about Leadership Skills. Do not confuse leadership with management. A person with good leadership skills can inspire and motivate individuals to perform. Leadership is often informal and subtle.

On the other hand, management is overt and uses hierarchical leverage, including the carrot and stick philosophy. Some managers, although they have license to use hierarchical leverage, use leadership skills to get things done through others. Be mindful though, that to be a good leader does not require one to be a manager. There are a great many powerful people in business and politics who are strong leaders, but not formal leaders.

A good leader will recognize the deficiencies they have and close that gap by leveraging the skills of another to complete the investigation. In such cases, the person leading an investigation will pull together an investigative team, bringing together different skill sets and perspectives to enable a robust investigation.

It is important to recognize that leadership skills are not easily acquired and that leadership is not easily won. It takes continual practice, willingness to accept feedback and learn from ones mistakes, and the tenacious building of trust.

As you work through investigations, think about your leadership skills. Are you burning bridges or building relationships? Leaders build relationships. Successful investigations cannot be completed in a corporate environment without good leaders who build good relationships. In fact, many organizations have the philosophy that they will hire people with leadership skills, because such skills are hard to develop; technical skills they can easily buy.

How have your investigations been going? Perhaps it's time to investigate your leadership skills!

This is an exciting new world I've been introduced to!

I get links to different blogs from time to time. They come from family and colleagues. Some are random and uninvited. However, I am amazed at the power of the blog as a communication tool. Many have embraced the value this vehicle for communication has in expressing and promoting themselves and their ideas and/or businesses.

The purpose of my blog is two fold: First to solicit and share ideas about Root Cause Analysis (RCA) in the manufacturing/operations arena. Second, to capture ideas and notes for my current book project on the subject, to be entitled: Finding Fault.

Hopefully, you will find this as helpful to yourself, as it is to me. So sit tight, fasten your seat belt and hang on for the ride!