BLAME

BLAME makes me sick! Blame is the most significant roadblock to positive change! He did not read the procedure! She did not do an MOC! It wasn’t me it was you! This is all blame and until we get over it we will not change or learn from things that go wrong. I do it, you do it, most everyone around us does it, but until we let go of blame we will not learn everything we can from things that go wrong. Sure we will learn that the valve lifted and this is usually where we stop. We found out why the failure happened; the valve lifted! Some organizations want to understand, so they ask “why did the valve lift”. Well, the valve lifted because the differential pressure was lost. But why was the differential pressure lost? Because the differential pressure sensing line was plugged. Why was the differential sensing line plugged? Because the differential sensing line root valve was plugged. Why was the differential sensing line root valve plugged? Because the wrong valve was installed which allowed sulfur to build up in the valve body and plug the valve. BINGO we found out who did it! The engineer put the wrong valve in. The operator new this was the wrong valve. The inspector looks at this valve every day why didn’t he catch it. What should we do? Move on and attempt to understand more. Do not stop here! Did you hear me, DO NOT STOP HERE! This is blame, find out who did what wrong and stop. Now let’s ask why. Why was the wrong valve installed and not recognized. If we let go of BLAME and try to understand to such an extent that we would have used the same valve, we will truly learn from things that go wrong.