We respond to problems quickly and rationally, with appropriate focus and engagement.  We recognize the importance of fixing a problem without analysis in some cases.  We do this when the problem is judged to be “acceptable,” i.e., when a similar recurrence can be tolerated.  In other cases, we attempt to address the causes of the problem so that it does not recur.  We do this when the problem is judged “unacceptable” – when a similar recurrence cannot be tolerated. 

Our organization has put a lot of thought into distinguishing between “acceptable and unacceptable,” and the vast majority of employees understands and agrees with this distinction. 

In all cases, however, we tend to wonder “why did this occur,” even when a light-bulb burns out (for example). 

When we attempt to understand the causes of the problem, our ultimate objective is: 

• to minimize the possibility of an identical problem, both in the location in which it occurred and in other locations within the company.

• to address the underlying causes of the problem, both in the location in which it occurred and it other locations within the company, so that similar (seemingly unrelated) problems can be avoided.

Although we certainly learn from our own mistakes, we put just as much effort into learning from other people’s mistakes – both within and outside the company.