How many times have you read an incident report and have been left wondering what was being investigated, or what the causal relationships were all about? You are often required to interpret the information, using your own knowledge to fill in the gaps. If you didn’t have any of the information or knowledge necessary to be able to understand the incident, then you would have had little clarification by reading the report.
This often occurs when vague or nebulous descriptors are used to explain causal relationships.
It would be an indication that the actual causes, causal relationships have not been clearly understood. By using a descriptor such as “poor” to describe say maintenance for example, I would have satisfied the need to find a cause for an effect, which in this instance may have been a “lack of lubrication”.
The use of this word in fact has a twofold effect. Firstly it leads easily into the categorising of causes for one. We are easily led to “Human error” in this instance, by making subjective assessments of the maintenance which is driven by the “poor” reference to it, and we are then moving quickly down a blame path. The results of this are typically some sort of sanction or warning, some retraining might be perceived to be warranted or a new procedure is written and added to the multitude of other such procedures that already exist. One or all of these actions may occur. When categorical thinking, like “human error” eventuates, we will tend to end up with the same generic types of solutions for each category.
It is categorical thinking, the pigeon holing of causes into common themes, that also allows subjective assessments and judgements to be made and this may happen in the complete absence of any facts. It is based on opinion and in the lack of any clear description is hard to deter or argue against.
A secondary effect of using words like” poor”, “inadequate”, “ineffective” , “insufficient” is that they are often emotive, inflammatory, and can lead to conflict.
When effective, unbiased communication is needed to understand an event, it is the advent of conflict or the perception of blame that are primary reasons why little progress is made in understanding causal relationships.
e.g. if I were to describe the maintenance of a machine as “poor” then the maintainers would arguably take offence to this and will react accordingly.
Now let’s examine the word “poor” itself. If I were to say that the word “POOR” is such a “poor” word, what is it that I would be trying to say? To someone it means one thing, to someone else it means something completely different and yet both are entitled to their understanding because the word itself is inclusive of everything. In fact you could take all of the possible reasons why it is poor, wrap them up into one huge collective bundle and just throw it out there by saying that it is “poor”.
“Poor maintenance” for example……what does this term actually describe? And the answer is everything that could possibly be poor about maintenance. It is imprecise, vague, and allows people to hide behind a cloak of communal misunderstanding. i.e. Almost everyone accepts it (because they do it themselves).
You will often find reference in a chart to faults or failures. i.e. the machine was laid up because of a mechanical failure. This is another example of an imprecise description of causes. I mean how many different types of mechanical failure are there? If you were to start listing them for any particular machine, the list would be a long one. The term “mechanical failure” in the initial context actually refers to only one of these, not all of them. This represents either a failure to understand the event or a failure to describe it in a way that other people can understand.
Either way it can lead to assumptions and misinterpretations, to subjective assessments of problems, to categorical thinking and more generic solutions.
As a facilitator, whilst accepting the “imprecise” description in the first pass at finding and unearthing causes, I am aware that it is not right. I know I need to get back to it and challenge it. As a means of clarification I will ask something to the effect of …”what is it that makes the maintenance poor?” The answers to this question need to be in the chart. By challenging the imprecise words consistently you will create CLARITY where previously there was none. Do this for all of those “imprecise” words that so frequently are littered throughout a chart and the report that follows.
Then you have causes that are characterised by what I would call “non description”. Causes which are simply referred to, but understanding relies completely on how you interpret them. Examples of this would be ……
“Time”…it was “the shaft was worn” because of “wearing” over “time”.
“Speed”….”car crashed” because the person didn’t see the other car” and “speed”.
“Age”……the pipe “corroded” because it was a “metal pipe” and “age”.
“Weight”……we couldn’t stop it because it was “rolling” and its “weight”.
Another example of a different context would be “maintenance”….i.e..the machine failed because of “maintenance”. The intent of this very vague reference would be to suggest that some aspect of the maintenance has been less than adequate but if we take this reference literally it would simply fail to make any sense. In other words what you are saying is that the “maintenance has caused the machine to fail”. Now I will agree that this is not the intent of the causal connection to say this, but it actually is what is being stated literally. It is the absence of a suitable description, a “non-description” if you like, that leads to this interpretation.
Now whilst all of these causes probably have some specific relevance within the causal pathways in which you find them they all create confusion as there is no clear descriptor to explain the relationship. This will again lead to subjective assessments. People will interpret the reference in their own way. Speed will mean different things to different people, as will weight, age and time. Typically what is required is to quantify each of these words. In other words
“How much time are you talking about?”
“What was the speed?”
”How old is it?”
“How heavy is it?” and
“What is it about the maintenance that was less than adequate?”
It is this information that the chart requires. Try to be as precise as possible here. This will create a far better understanding. By simply referring to a cause, without accurately describing it, you demand that the reader interpret it in the same way that you do. But this is an assumption. Everyone is different. There is not one of us, as humans, that is exactly the same as anyone else. It is the human condition. Everyone is unique, the sum total of all of their life experiences to date. So it would be erroneous to assume that all people think the same way. Then why do we ask them to do so?
Now I would suggest that this is not so. That this is not what we are trying to do. That this is not a deliberate expectation, but it is the result, none the less, when we present information in this fashion.
Another area in which language plays a significant role in the understanding of a particular causal factor is where the descriptor makes a judgement call. Words like “wrong, or “incorrect” are used to describe causes. This sort of description is purely subjective, opinionated and may not be based in fact. If what we are trying to do is to present the facts then these types of words would fail to achieve that. Your task as a facilitator is to seek clarification of these words. Why is it wrong? What makes it wrong or incorrect? When these questions are asked the responses to them need to be recorded and added to the chart. The original reference has been replaced by something far more factual and meaningful. It also makes your charts easier to understand. The chart will become more transparent. Remember that you are trying to tell the story, rather than ask people to guess, or infer what has happened with vague or imprecise descriptions of causes.
The task of charting the incident is also made easier because it is now easier to find and arrange causes that have a precise description rather than a vague one.
The logic will become clearer and the chart easier to follow and understand.
Understanding our problems is the cornerstone to finding effective solutions that will prevent reoccurrence. It is our ability to apply our understanding of the impact of clear and precise communication that will have a tremendously positive impact in this pursuit.
This often occurs when vague or nebulous descriptors are used to explain causal relationships.
It would be an indication that the actual causes, causal relationships have not been clearly understood. By using a descriptor such as “poor” to describe say maintenance for example, I would have satisfied the need to find a cause for an effect, which in this instance may have been a “lack of lubrication”.
The use of this word in fact has a twofold effect. Firstly it leads easily into the categorising of causes for one. We are easily led to “Human error” in this instance, by making subjective assessments of the maintenance which is driven by the “poor” reference to it, and we are then moving quickly down a blame path. The results of this are typically some sort of sanction or warning, some retraining might be perceived to be warranted or a new procedure is written and added to the multitude of other such procedures that already exist. One or all of these actions may occur. When categorical thinking, like “human error” eventuates, we will tend to end up with the same generic types of solutions for each category.
It is categorical thinking, the pigeon holing of causes into common themes, that also allows subjective assessments and judgements to be made and this may happen in the complete absence of any facts. It is based on opinion and in the lack of any clear description is hard to deter or argue against.
A secondary effect of using words like” poor”, “inadequate”, “ineffective” , “insufficient” is that they are often emotive, inflammatory, and can lead to conflict.
When effective, unbiased communication is needed to understand an event, it is the advent of conflict or the perception of blame that are primary reasons why little progress is made in understanding causal relationships.
e.g. if I were to describe the maintenance of a machine as “poor” then the maintainers would arguably take offence to this and will react accordingly.
Now let’s examine the word “poor” itself. If I were to say that the word “POOR” is such a “poor” word, what is it that I would be trying to say? To someone it means one thing, to someone else it means something completely different and yet both are entitled to their understanding because the word itself is inclusive of everything. In fact you could take all of the possible reasons why it is poor, wrap them up into one huge collective bundle and just throw it out there by saying that it is “poor”.
“Poor maintenance” for example……what does this term actually describe? And the answer is everything that could possibly be poor about maintenance. It is imprecise, vague, and allows people to hide behind a cloak of communal misunderstanding. i.e. Almost everyone accepts it (because they do it themselves).
You will often find reference in a chart to faults or failures. i.e. the machine was laid up because of a mechanical failure. This is another example of an imprecise description of causes. I mean how many different types of mechanical failure are there? If you were to start listing them for any particular machine, the list would be a long one. The term “mechanical failure” in the initial context actually refers to only one of these, not all of them. This represents either a failure to understand the event or a failure to describe it in a way that other people can understand.
Either way it can lead to assumptions and misinterpretations, to subjective assessments of problems, to categorical thinking and more generic solutions.
As a facilitator, whilst accepting the “imprecise” description in the first pass at finding and unearthing causes, I am aware that it is not right. I know I need to get back to it and challenge it. As a means of clarification I will ask something to the effect of …”what is it that makes the maintenance poor?” The answers to this question need to be in the chart. By challenging the imprecise words consistently you will create CLARITY where previously there was none. Do this for all of those “imprecise” words that so frequently are littered throughout a chart and the report that follows.
Then you have causes that are characterised by what I would call “non description”. Causes which are simply referred to, but understanding relies completely on how you interpret them. Examples of this would be ……
“Time”…it was “the shaft was worn” because of “wearing” over “time”.
“Speed”….”car crashed” because the person didn’t see the other car” and “speed”.
“Age”……the pipe “corroded” because it was a “metal pipe” and “age”.
“Weight”……we couldn’t stop it because it was “rolling” and its “weight”.
Another example of a different context would be “maintenance”….i.e..the machine failed because of “maintenance”. The intent of this very vague reference would be to suggest that some aspect of the maintenance has been less than adequate but if we take this reference literally it would simply fail to make any sense. In other words what you are saying is that the “maintenance has caused the machine to fail”. Now I will agree that this is not the intent of the causal connection to say this, but it actually is what is being stated literally. It is the absence of a suitable description, a “non-description” if you like, that leads to this interpretation.
Now whilst all of these causes probably have some specific relevance within the causal pathways in which you find them they all create confusion as there is no clear descriptor to explain the relationship. This will again lead to subjective assessments. People will interpret the reference in their own way. Speed will mean different things to different people, as will weight, age and time. Typically what is required is to quantify each of these words. In other words
“How much time are you talking about?”
“What was the speed?”
”How old is it?”
“How heavy is it?” and
“What is it about the maintenance that was less than adequate?”
It is this information that the chart requires. Try to be as precise as possible here. This will create a far better understanding. By simply referring to a cause, without accurately describing it, you demand that the reader interpret it in the same way that you do. But this is an assumption. Everyone is different. There is not one of us, as humans, that is exactly the same as anyone else. It is the human condition. Everyone is unique, the sum total of all of their life experiences to date. So it would be erroneous to assume that all people think the same way. Then why do we ask them to do so?
Now I would suggest that this is not so. That this is not what we are trying to do. That this is not a deliberate expectation, but it is the result, none the less, when we present information in this fashion.
Another area in which language plays a significant role in the understanding of a particular causal factor is where the descriptor makes a judgement call. Words like “wrong, or “incorrect” are used to describe causes. This sort of description is purely subjective, opinionated and may not be based in fact. If what we are trying to do is to present the facts then these types of words would fail to achieve that. Your task as a facilitator is to seek clarification of these words. Why is it wrong? What makes it wrong or incorrect? When these questions are asked the responses to them need to be recorded and added to the chart. The original reference has been replaced by something far more factual and meaningful. It also makes your charts easier to understand. The chart will become more transparent. Remember that you are trying to tell the story, rather than ask people to guess, or infer what has happened with vague or imprecise descriptions of causes.
The task of charting the incident is also made easier because it is now easier to find and arrange causes that have a precise description rather than a vague one.
The logic will become clearer and the chart easier to follow and understand.
Understanding our problems is the cornerstone to finding effective solutions that will prevent reoccurrence. It is our ability to apply our understanding of the impact of clear and precise communication that will have a tremendously positive impact in this pursuit.
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