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Book Review

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What You Can Learn from Things that Go Wrong

A Guidebook to the ROOT CAUSES of Failure

First Edition

C. Robert Nelms
Review (from Chapter 1:  Failure is NOT What You Think It Is!)

Is this book for you?  Maybe, or maybe not.  It depends on whether or not you are interested in understanding why things go wrong.  Some people don't seem to care.  Others care passionately.  I am among the later.

This book is for anyone interested in learning from the "failures" in their lives.  I suppose business people will be most interested, but I think the learning is universal.

My experience with failure comes largely from working inside complex industrial facilities.  Many of the examples I'll use will come from this environment.  But industry is not special -- it is run by people, just like everything else.  And people cause failure.  Yes, that's right -- I said people cause failure.  When we hear on television that human error causes such and such a disaster, most of us get the wrong impression.  The news media makes it wound as if in some cases, humans are not responsible.

But when you dig deep enough, everything that goes wrong is caused by people -- everything.

I'm going to assume that you, the reader, would like to learn a discovery process that will lead you to the root causes of things that go wrong in your "world."  If you're not interested in learning a discovery process, you've got the wrong book in your hand.

I'm also going to assume that you're interested in what I've learned, i.e., not only how to learn, but what I've earned.  In fact, that's where I'm going to begin.

As far as I am concerned, "failure" is the single most unique subject in our existence.  All subjects which deal with "success," i.e., how to build things, how to run things, how to grow things, in general how to do things are different from this subject.  Failure is disturbing to talk about.

From Back Cover

Here is everything you will need to successfully identify the true ROOT CAUSES of things that go wrong in your place of business.  You will learn a comprehensive step-by-step discovery process.  You will be exposed to the many barriers which impede progress in this area, with plenty of suggestions of how to overcome them.  You will see how others have successfully addressed failure.  But perhaps most importantly you will discover what Mr. Nelms discovered -- that there might be only one root cause of everything that goes wrong in our lives...
Table of Contents
Chapter 1 Failure is NOT What You Think it Is.
  The Secret to Success is Failure
  Addressing the Mindset
  The Seed Analogy
  Learning to Anticipate Failure
  Addressing the Root Causes of Failure
  The Unavoidable Philosophical Tint
  The Filter
  Blame
Chapter 2  EVERYONE Can Be Looking for Root Causes
  The WHY Switch
  The WEED Analogy
  The TOP-DOWN Approach to Root Cause Learning
  The BOTTOM-UP Approach
  Into the Depths of the Bottom-Up Approach
  Timing is a Key
Chapter 3  An Introduction to the TOP-DOWN Approach
  Identifying the Target
  Setting the Sights
  Pull the Trigger
Chapter 4  How to Identify Your MOST SIGNIFICANT Problems Fast!
  Far from Natural
  Corporate Conscience
  How to Identify the Significant Few
    Defining "Failure"
    Combing for Events and Conditions which Meet the Definition
      Failure Modes and Effects Analysis
      The Contact Principal
      The Contact Diagram
      Bubbling-Up the "Biggies."
    The Kinds of Failures You'll Find
    Chronic versus Sporadic Failure
Chapter 5  A Root Cause Discovery Process -- "ROOTS"
  A Cookbook
Chapter 6  RESPONDING to Failure ("The Devil is in the Details")
  The Important of Freezing Evidence
  Let's Talk about Evidence
  Become One With the Failure
  The 4 Ps
    People Evidence
    Positional Evidence
    Parts Evidence
    Paper Evidence
  Making the Freezing of Evidence a Part of the Way You Do Business
    Two Tracks are Necessary
    A note about On-The-Job Training
    How to Call the Investigator
    How to Prepare 5 Items
    The GoBag and the GoBook
    Investigative Guidelines
      Investigative Position-Mapping and Parts Gathering Guidelines
      Investigative Interviewer Guidelines
      Paper Evidence Checklists
Chapter 7  ORGANIZING the Investigation to Help You "Break the Shell" of Understanding
  The Perfect Principal Investigator
  The Breaking of the Eggshell is Somewhat Painful
  Forming the Team
  The Team Meeting, In General
  Before Your First Team Meeting, Have a Plan
  Suggested Roles to Help Establish Control
  The First Team Meeting, a Suggested Agenda
  The Value of Persisting
Chapter 8  Using the WHY Tree to find the ORDER within the Chaos
  The Domino Effect -- the Beginning of Structure
  The WHY Tree is NOT:
  The Simplicity of the WHY Tree
  Getting to Physical Cause
    Start with the Top Block
    Develop the First Row
    Take Small Steps into the Tree
    Ask "How or Why"
    Assure that Each Row is All-Inclusive / Comprehensive
    Use Evidence to "Rule-Out" or "verify" Hypotheses Immediately, When Possible
    Push Beyond the Available Evidence
    Use the 5,3,1 Rule
    The Pathway Down the Tree
    Using Either/Or When You get in a Jam
  Verify What You've Hypothesized -- One Row at a Time, by Gathering More Evidence
  The Verification and Action Logs
  The Verification Process
  Succeeding Team Meetings
Chapter 9  Probing the Depths of Things that Go Wrong (ORDER, continued)
  The Hint of One, Very Meaningful Root
  The Domino Effect, Revisited
  Physical versus Management Systems
  Management Systems Domino
  Situations
  The Filtering Process
  Brainwashing
  Our Filters are Easily Contaminated
  Inside the Filter
  The Investigative Analysis Path
  The Makeup of the Filter
  The Root Cause of All Failure?
  A Practical Way of Addressing Root Cause
Chapter 10  What is this Issue called "Latency?"
  People are the Triggering Mechanisms of Failure
  Discipline Turned Sour When Not Directed at Latency
  Latency Synonyms
  The Direct Approach to Latency
  The Indirect Approach to Latency
  A Word on Pre-Defined Categories
TRANSLATING Your Findings so Everyone Can Understand -- or -- So Now that You Know the Root Causes, SO WHAT?
  How to Make the Invisible, Visible
  Translate Your Findings
    The Documentary
    The Translation
    The Cartoon Report
  Presenting Your Translation
    For Information Transfer
    Foe Decision-Making
  Distributing Your Translation
Chapter 12  How to SELL Your Root Cause Results -- or -- Why Won't Anyone ACT on Our Findings
  Review of Root Cause Obstacles
  Something Different, or Nothing Changes
  The Sales Process
  The Executive Response to a Root Cause Effort
  Acceptance Criteria
  Review Boards and Tracking Systems
Chapter 13  The Bottom-Up Approach to Root Cause Discovery
  The Bottom-Up Approach is Not:
  The Invisible Bottom-Up World
  The Key to Bottom-Up Analyses -- Acknowledging, then DWELLING Within the Situations We Encounter
  What Situations Do Each of Us Encounter as We "Do Our Thing" at Work?
  What is a Situation?
  The Difference Between a Situation and a Problem
  Intentionally Driving Towards Discomfort
  Your Significant Few Responses
  The Eggshell, Revisited
  Continuing the Drive Towards Discomfort
  An Example
  What is the Point of All This?