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7:25 pm
June 11, 2012
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Kübler-Ross And Root-Cause Evaluations

0612noon

While the nature of bad news may differ, people react in strikingly similar ways when they receive it.

In her 1969 book entitled On Death and Dying, Dr. Elisabeth Kübler-Ross, a Swiss psychiatrist who had studied behavior-coping patterns related to death and other life-changing events, introduced the “Five Stages of Grief” concept.

Her model was based on extensive research with more than 500 patients who had been told that they would soon die. The five stages are: 

  • Denial: “You must be mistaken; you are incompetent; this can’t be happening to me; the tests are wrong.”  
  • Anger:  “This is not fair; why me; this is your fault; things like this don’t happen to me.”
  • Bargaining:  “Please Lord, give me a little more time and I will make up for what I have done (or not done); what can I do to live longer, I’ll pay whatever it takes; what about those hospitals in [foreign country] that claim to fix this condition?”
  • Depression:  “I might as well kill myself; what’s the point now, I’m going to die anyway; go away and just leave me alone; no one understands what I am going through.”  
  • Acceptance: “OK, let’s deal with this; let me get on with the rest of my life; time to put things in order.”  

All of these stages aren’t necessarily experienced by all people—or in the same sequence. For example, some may experience anger before denial. Others may go through just two or three stages. Some may even become stuck in one stage and never move into another. 

The individual behavior model put forth by Kübler-Ross resembles one developed in the 19th century by Dr. Arthur Schopenhauer to describe acceptance of new ideas that challenge the status quo. Schopenhauer said that such an idea is first ridiculed, then rejected—sometimes maliciously—as supporters of the status quo resist change. When acceptance finally occurs, people may claim the idea was self-evident all along. Similarly, Dr. Max Plank, a Nobel Prize-winning physicist in the late 19th and early 20th centuries, is often quoted as saying that only when adherents to the old paradigm die can the new paradigm be accepted. (The paradigm to which he referred was quantum mechanics.)

Having been involved in the formal investigation of adverse events for many years, I’ve observed that something akin to the “Five Stages of Grief” also occurs when root-cause reports are presented. Let’s say that an adverse event has taken place. After a thorough investigation, a root-cause evaluation report is prepared regarding the who, what, when, where, how and why. (It may also recommend corrective actions.) This report (perhaps in draft form) is then given to a committee for consideration.

The committee typically includes at least some managers whose departments were involved in the adverse event. Some of them may even have made decisions that set up conditions for the event, exacerbated its consequences or directly caused it. Some might have had an opportunity to prevent the event, but didn’t act. Thus, the committee isn’t impartial: It’s like a patient with a stake in his/her doctor’s diagnosis of a serious condition.

Consequently, if the root-cause investigation uncovered serious problems that require significant changes, the group dynamic of the committee may experience something strikingly similar to the “Five Stages of Grief.” They are:

  • Denial:  “Your facts are incorrect and your analysis wrong; we have awards saying WE don’t make those kinds of mistakes; our training program specifically addresses this issue.”    
  • Anger:  “You had it in for us before you even started; you didn’t listen to us when we told you what really was wrong; you don’t understand how this industry really works; you’re providing ammunition to the lawyers; we thought you were on our side.”
  • Bargaining:  “OK, we understand your point, but let’s word things a little differently; maybe leave THIS part out; why do you want to make us look so bad; can we add more about what we did right (you left THAT out); can’t we just fire the people responsible?”
  • Depression:  “We’ll go bankrupt trying to fix this; we don’t have the time to make these changes; might as well close down that department and lay off everyone; workers will quit if this gets out; our reputation will be ruined; the local news media will humiliate us; the regulators are going to have a field day with this.”
  • Acceptance:  “Yes, we messed up; let’s do what it takes to get this problem fixed and back to business.”   

Because this is a group dynamic, the committee may experience several stages at the same time rather than progressively. Denial and anger, or bargaining and depression, for example, are often coupled together. The result is that no matter how well written the report is or how well the findings are presented, committees often won’t accept a first version. 

Frequently, new material to be included in a report—or requested wording changes—will not alter the fundamental conclusions. In fact, the basic findings of a root-cause investigation can usually be stated in one page or less. The rest of the report, which often consists of pages of related details, administrative requirements and investigative narrative, provides context. 

If a doctor says to a patient, “You have a dreadful disease and must undergo immediate, extensive, painful, expensive treatment, so be here tomorrow morning to get started,” the appropriate response probably won’t be evoked. That’s because context is missing. While basic information has been provided, most patients would want (and need) to know more. The same holds true for root-cause investigation reports.

The fact that the first presentation of root-cause findings may be rejected doesn’t necessarily reflect on the quality of the work that went into the investigation. Less-experienced investigators sometimes view these rejections as personal shots at their work product. Barring that a report demonstrates shoddy writing, deficient investigation methods and/or flawed logic, such perceptions are typically unfounded. Initial rejection often means that a committee just needs more time to assimilate the findings on their own terms—much like a patient receiving bad news from a doctor. 

Therefore, the sometimes iterative process of presenting, rejecting, modifying and then again asking for additional changes to a root-cause report serves a useful purpose: It demands that the approval committee carefully read and consider the findings. Trying to disprove the findings (and their supporting evidence) requires that they be thoroughly understood. Moreover, incorporating changes that are personally recommended by committee members—in context—increases those members’ personal stakes in a report. This, in turn, allows them to reach the “Acceptance” stage on their own terms. Those are good outcomes. MT

Randy Noon is a Root-Cause Team Leader at Nebraska’s Cooper Nuclear Station. A frequent contributor to MT, he’s been investigating failures for more three decades. Noon is a licensed professional engineer in several states and the author of a number of books on failure. Email: rknoon@nppd.com.

 

 

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