In his book 'Deep Survival' Laurence Gonzales talks at one point
about one of the factors that does in young US Navy pilots who are
learning to land jet aircraft on the moving, swaying deck of an
aircraft carrier at night. The factor that gets them in trouble -
and kills a small percentage of them and nearly kills many more -
is that despite consciously knowing they should not come in too low
they subconsciously desire so much to be lower because lower means
'safety' (i.e., landing) on a deep emotional level that is quite
difficult to override when you're under enormous stress. They know
to not come in low, that being too low is the greatest danger to
them, but their own emotional-subconscious drives them to do it
anyway.
Similar problems are at work undermining the majority of attempts
at root-cause analysis of quality problems. People are so geared to
find solutions, propose solutions, get on with fixing things that
they will begin to work on 'fixing' something that if you ask them
they will admit they do not know the cause and will even claim they
are working on root-cause analysis. They will do this even as
they are proposing fixes to try out or even in the middle of
implementing them! They may even tell you that they know you have
to get to a root cause before working on solutions or you have no
real chance of solving the problem - even while they've been saying
they know it's inadequate drying of the mold wash that's causing
the loose sand defects in the castings and the molds need to be
dried longer. It is so comfortable and comforting to be talking
about solutions you can implement that we skip right on over
finding the cause first. Finding and implementing solutions is
rewarded. Putting out fires makes you a hero. Almost no one sees
the value of finding the actual cause and finding a good permanent
solution.
