We have learned the futility of blaming one another on our problems.  The vast majority of our employees understand that they each have a role in the things that go wrong in our company.  Our intent during an RCA is for each of us (individually) to see how we personally need to change as a result of an unacceptable problem.  Finger pointing is virtually non-existent at our company.

Whereas we used to merely try to understand the “physics” of our problems, and then were satisfied with stopping at the “human” (who did what), we are now focused on “what about the way we ARE contributed to this event?”  Each of us asks ourselves this question as a result of an incident.

Whereas we used to focus on the “past” (and even used past-tenses to describe the causes of our problems), we are now focusing on the present – seeking to acknowledge the way we are that will continue to cause problems if not addressed.

The practice of looking for our own role in things that go wrong has become habitual within most of our employees.