A Little History About How I Came Across Learning Teams.
A little over three years ago I was asked to speak at a conference that was entitled, Human Performance, Root Cause and Trending or HPRCT (great conference BTW and I encourage you to attend). This was a different world for me as I typically attended and spoke at Reliability and Maintenance trade conferences, but I was interested to see what it was all about (plus a good friend of mine was the one who invited me).
I'll start by saying that I met the most gracious, experienced and intellectual people at this conference who welcomed me into their space. While we may have differences in opinion, to me, that is our collective strength in exploring ways to progress our respective fields. As far as I'm concerned...we have unity in purpose! As a result I continue to attend this conference until this day, because I continually learn from these different perspectives and many of these folks have become my friends.
I remember my first year attending HPRCT and hearing numerous speakers reference 'HPI'. The only time I had ever heard that term prior was in my healthcare related work, where a prominent consulting company led by Craig Clapper was called Healthcare Performance Improvement or HPI. I actually had to ask one of the conference organizers what the term meant because I did not know. It stood for Human Performance Improvement which is not a well-known term in the Reliability and Maintenance spaces.
I started becoming aware that HPI was truly the focus of this conference. I began realizing this HPI was a subset of a movement led by Safety progressive Dr. Sidney Dekker, a very well-respected and noted Safety research scientist and academic. His movement is referred to as Safety Differently and is the title of one of his many books.
As I listened to more and more speakers on this HPI topic, they kept referencing the term 'Learning Teams (LT)'. They routinely discussed the benefits of a LT but I was not clear on how a learning team was conducted. What caught my attention was comments made by Dr. Dekker, Dr. Conklin and advocates of LT's that 'RCA' was obsolete and old school, and that LT's replaced the need for RCA. That really caught my attention, as did it catch the attention of 1/3 of the audience who practiced in the RCA field.
However, as veteran RCA analysts, we have to practice what we preach. We have to be open-minded, formulate hypotheses, gather evidence and separate fact from fiction. Those promoting LT's are very intelligent people, so I wanted to explore what is behind this LT concept and are there attributes to it, that could improve upon RCA as I define it?
How Do Learning Team Practitioner's View 'RCA'?
I wrote a white paper on this very topic a while ago entitled, Do Learning Teams Make RCA Obsolete?. It was a lengthy paper that detailed what I consider effective 'RCA' to be. So in this paper, I will not expand on that, but just reference it as the basis for this discussion.
Since writing that paper, I have attended several other safety conferences where HPI is a prominent topic. I've talked to several speakers who presented on this topic and I have learned a lot. I never saw the two approaches as competitive (either/or), I see them as complementary.
I want to reflect on what I perceive as restraining paradigms the Safety space has about ‘RCA’:
- RCA is a component-based property and not a systems-based property
- RCA only focuses on broken parts
- RCA represents linear thinking
- RCA concludes with a single cause
- RCA does not explore the human contribution to an undesirable outcome
- RCA does not explore organizational system deficiencies
- RCA has been around a long time and proven not to be effective
Based on my 30+ years as a practitioner in the 'RCA' business, all of the above are not consistent with how we apply our PROACT RCA Approach. However, does that make their perceptions wrong? No! I cannot negate the fact that many (if not most) apply 'RCA' ineffectively. There are a number of reasons for this. I outlined many of those reasons in this video about an RCA conducted on 'Why RCA Efforts are Not Meeting Expectations'. We as veteran analysts cannot ignore the fact that many in our industry conduct 'Shallow Cause Analysis' versus Root Cause Analysis. Many treat RCA as a checklist item and will do the minimum required to get the task off their plate. Leadership also plays a role in RCA's ineffectiveness because they accept low quality RCAs. Therefore they lower the standard of acceptability and condone the concept of Shallow Cause Analysis.
We all know RCA analysts that will:
- Conduct serious investigations using inappropriate tools like 5-Whys, which cannot express the appropriate breadth and depth needed to explore a complex failure.
- Draw conclusions based on hearsay and not sound evidence.
- Stop an analysis and conclude a deficiency about a failed component.
- Stop an analysis and blame a decision maker.
- Conclude an analysis with a single cause.
In fairness to the Safety community's perception of RCA, much of it is earned by the RCA field! This does not mean there is not a minority of veteran analysts who are dedicated to the effective implementation of RCA, it just means they are the exception and not the norm.
How Do I Now View Learning Teams?
Notice in this sub-title I am not saying how does the 'RCA' community view LT, just me, I can't speak for the other RCA approaches, I can only speak for my own experience and approach.
I want to reflect on what I perceive as potential paradigms the RCA space has about the concept of ‘Learning Teams (LT)’:
- LTs draw conclusions about failures based on a couple of 2-hour sessions over 2 days (including the over-night 'soak' time)
- LTs draw conclusions based on hearsay and not based on collected evidence
- LTs do not focus on an 'incident' but rather the generalities of people's roles, which happened to be involved in an incident being analyzed. The incident is not the focus, but the daily roles are.
- LTs focus on daily routines and seek feedback from its team members on opportunities for improvement in their workplaces.
- LTs do not formally document results of their sessions, in terms of creating a LT corporate database where all LT information could be queried for trends across the corporation.
- LTs do not leverage their findings across the corporation, as each situation is unique and unlikely applicable to others in the corporation.
- LTs strive to create a trusting environment and a key attribute is they are able to act on their findings quickly.
I admit it has been difficult to find what the 'norm' for a LT is in actual practice, as various providers evidently view their purpose and intent differently (as is the same in the RCA space). Like RCA, LTs operate in a competitive space and therefore there must be marketing uniquenesses. Keep in mind this list represents perceptions only of the LT concept. I would be very interested in hearing from LT practitioners about their realities as opposed to these perceptions.
However, I would like to note and many LT practitioners also conduct RCA's, so they do not accept the position that RCA is 'obsolete'. Rather they see there is a time and place for each approach and a skilled analyst will know when to use the appropriate tool.
So, Are RCA's and LT's Friends or Foes?
So with all this background, what epiphany have I had personally about the differences/likenesses between RCA's and LT's?
- With regards to the application of our own PROACT RCA methodology, I will now advocate for the inclusion of a skilled HPI/LT facilitator on our RCA teams for SIFs (Serious Injuries and Fatalities), Catastrophic Losses and Unacceptably High Risks.
- I recognize the added value of the unique interviewing/facilitating skill sets of an expert LT facilitator, and that is of value when exploring human reasoning in our RCA approach. The LT interviewing style is less threatening and more broad-based than that of a traditional, more pointed RCA interview.
- RCA's are traditionally led by engineers who are notoriously left-brained, logical thinkers. RCA excels based on its in-depth knowledge of the physical sciences. LTs are traditionally led by those trained in the social sciences, who are typically right-brained, conceptual and creative thinkers. LTs excel based on their in-depth knowledge of the social sciences. Both skill sets are required to solve undesirable outcomes in my mind.
- There is a place for both RCA and LTs. RCAs are often employed when there is a presence of physical damages resulting in an undesirable outcome. LTs will often yield to RCAs in such cases. However, in the absence of such physics being involved, and the undesirable outcome may be a serious injury, fatality or high risk thereof, a LT may be more appropriate. Of course there will be cases where 'it depends, based on if there is legal and/or regulatory involvement in the case at hand. Such situations then are typically going to require a focus on physical evidence to support findings and conclusions. A LT approach by itself may not be adequate enough for a legal defense. I am open to learning more from the LT community about this 'assumption' on my part.
In conclusion, IMHO, RCAs and LTs are complementary and NOT contradictory. I cannot see how one can be successful without the attributes of the other.
Note from the author: I am continually trying to narrow my gap in understanding between that of what I know to be 'RCA' and what I am learning about Learning Teams. Please feel free to educate me further on your experiences either, online or off-line. Blatino@reliability.com or visit www.reliability.com.
About the Author
Robert (Bob) J. Latino is CEO of Reliability Center, Inc. a company that helps teams and companies do RCAs with excellence. Bob has been facilitating RCA and FMEA analyses with his clientele around the world for over 35 years and has taught over 10,000 students in the PROACT® methodology.
Bob is co-author of numerous articles and has led seminars and workshops on FMEA, Opportunity Analysis and RCA, as well as co-designer of the award winning PROACT® Investigation Management Software solution. He has authored or co-authored six (6) books related to RCA and Reliability in both manufacturing and in healthcare and is a frequent speaker on the topic at domestic and international trade conferences.
Bob has applied the PROACT® methodology to a diverse set of problems and industries, including a published paper in the field of Counter Terrorism entitled, "The Application of PROACT® RCA to Terrorism/Counter Terrorism Related Events."