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

2. Everyone wants to change the world, but no-one wants to change themselves….. Leo Tolstoy, 1828-1910 (Russian author and philosopher)

3. Human Nature Its not me, its you. Its not us, its them. Its not people that cause our problems: its our equipment. its our systems. Human Beings LOVE to BLAME!

5. 14 statements were suggested to help rate the health of their sites 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.

6. 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

7. A quick vote.

8. No known function other than… to take over the resources of its victim

9. Cell Wall Nucleus Virus

10. Cell Wall Nucleus

11. Cell Wall Nucleus

12. Cell Wall Nucleus

13. The Human Psyche The mind, and its capacity to govern behavior

14. The Human Psyche The mind, and its capacity to govern behavior Its not me, its YOU!

15. 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 Ill ask if you agree with the essence of the comments. 9:30

16. 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

17. From http://www.yahoogroups.com/group.rootcauseconference It doesnt 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

18. 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

19. 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)

20. From http://www.yahoogroups.com/group.rootcauseconference Do you agree with the essence of the comments? 13:00

21. Yes, people are almost always at fault. Interpersonal relationship problems

22. Yes, people are almost always at fault. Interpersonal relationship problems When something goes wrong within a system that we have created

23. 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.

25. 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?

26. Its partially my fault. 25:00

27. 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)

28. 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)

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

30. I blame my mother for nothing, but forgive her for everything…. Mary Blige (Rhythm and Blues Singer and actress)

31. It simply makes more sense for everyone to look at themselves instead of everyone pointing their fingers at others. Agree?

32. It simply makes more sense for everyone to look at themselves instead of everyone pointing their fingers at others. But human nature being what it is, is this even possible?

33. Small viral attack: Primary Immune System Response 29:30

34. Adjacent Cells Prepare Themselves

35. Small viral attack: Primary Immune System Response

40. Well would you look at that! What kind of an idiot would have left the spigot on?

41. Small viral attack

42. BLAME ALERT – BLAME ALERT – BLAME ALERT Well would you look at that! What kind of an idiot would have left the spigot on? Thats not the way we do things in this family, Bruno.

43. We WILL NOT ACCEPT even a tinge of BLAME

44. 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.

45. Not even a tinge of BLAME Oh my! I remember seeing it also – and didnt do anything about it. I should have turned it off myself!

46. Not even a tinge of BLAME I have to admit that I often leave the faucet on, even after Im finished for the day. I guess Im thinking why turn it off if Ill use it tomorrow? Im the biggest culprit!

47. Not even a tinge of BLAME Lets all try to be an example to one another by not ever taking any shortcuts! In fact, lets see who can set the best example.

48. People cannot and will not feel responsible for ANYTHING when they are infected by the blame virus.

49. 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.

50. Massive Viral Attack Mass Invasion Alert!!!!!! 39:50

51. Massive Viral Attack: Calling the Secondary Immune System

53. 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!!!!!

55. FAST Contain then Restore

56. FAST Its 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!

57. FASTSLOW Its 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!

58. FASTSLOW The Causal Learning Function. The Root Cause Analysis Function. The Latent Cause Analysis Function. These functions ARE the organizational psyches secondary immune system… ….IF their goal is to replace BLAME with INTROSPECTION.

59. Any causal learning function that discourages people from looking at themselves is in itself a significant CAUSE of our problems.

60. A suggested 4-pronged antidote to the blame virus… …driven by a strong causal learning function at your site.

61. 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.

62. 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).

63. 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!

64. 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.

65. Administered by a strong causal learning function at your site… …with participation by all.

66. You dont 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

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

68. Operator TERMINATED!

69. Operations: Many of us have been sleeping at this particular control panel for years. It is not intentional! It is almost unavoidable. Its 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 didnt 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!

70. 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.