And its antidote
C. Robert (Bob) Nelms
Failsafe 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?

A quick vote.
Virus
Cell Wall
Nucleus
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
From http://www.yahoogroups.com/group.rootcauseconference
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
From http://www.yahoogroups.com/group.rootcauseconference
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
From http://www.yahoogroups.com/group.rootcauseconference
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
From http://www.yahoogroups.com/group.rootcauseconference
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)
From http://www.yahoogroups.com/group.rootcauseconference
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 sense
for everyone to look at themselves
instead of everyone pointing their
fingers at others.
Agree?
It simply makes more sense
for everyone to look at themselves
instead of everyone pointing their
fingers at others.
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
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.
BLAME ALERT – BLAME ALERT – BLAME ALERT
We WILL NOT
ACCEPT 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.
Not even a tinge
of BLAME
Oh my! I remember seeing it
also – and didn’t do anything
about it. I should have turned it
off myself!
Not even a tinge
of BLAME
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!
Not even a tinge
of BLAME
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.
Not even a tinge
of BLAME
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.
Mass Invasion Alert!!!!!!
Massive Viral Attack
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!
SLOW
Intentional,
Aggressive
Introspection!
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!
SLOW
The Causal Learning Function.
The Root Cause Analysis Function.
The Latent Cause Analysis Function.
FAST
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 suggested
4-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 reemphasize it when such things occur (in
anticipation of a mass invasion of the
blame virus).
We will insist on a corresponding selfdiscovery (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.
REQUIRED!
When (if) a catastrophe occurs, we will
encourage this policy to be strongly reemphasized (in anticipation of a mass
invasion of the blame virus.)
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!
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.
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.
Operator TERMINATED!
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.
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.
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 Nelms
Failsafe Network, Inc.