August 12, 2020 | Mark Paradies

How Can Blame Cause Accidents?

Blame Causes Accidents

Can Blame Cause Accidents?

Yes, blame can cause accidents. You might ask … But How? How can blame cause accidents?

That’s a good question. In the following sections, we will explain the link between blame and accidents.

Can Blame Change Behavior?

We all know what blame looks like but here is an example of blame and behavior.

An electrician goes out to work on some electrical gear. He knows that a lockout/tagout is required but the work will only take a minute. He just needs to flip a breaker, make, an adjustment inside the housing, and turn the breaker back on. What could go wrong?

When he gets to the worksite, he makes a mistake. He flips the wrong breaker. The breaker he flips shuts down a key piece of equipment. The loss of that piece of equipment causes the whole line to shut down. The boss is going to be mad.

The electrician resets the breaker and skedaddles. No one will know that he caused the problem. The cause of the lost production will never be known no matter what type of investigation they perform because nobody will confess to tripping the breaker.

Why did the electrician reset the breaker and skedaddle? Because he knew that if he admitted what he did he would be blamed for the lost production time and he might even get fired. That’s the fear of blame that is the result of previous blame (he had seen others get disciplined for mistakes).

But How Does Blame Cause an Accident?

Blane causes accidents

But how does that example of blame cause other accidents? Simple. If that incident would have been investigated, the electrician not using a lockout/tagout would have been discovered. Effective corrective actions to change this behavior could have been implemented. And the accident that happened two months in the future (where the electrician was electrocuted by taking a shortcut of not using a lockout/tagout) would have been prevented.

Thus, blame prevented thorough root cause analysis and effective corrective actions. Blame caused an accident.

But I Thought Discipline Prevented Accidents

Blame doesn’t cause accidents. Blame (discipline) prevents accidents!

I’ve heard that before. If someone breaks a rule, we have to punish them.  That’s the way our progressive discipline system works.

Have you heard that before?

But the person broke the rule even though they knew the discipline system was in place. WHY?

It usually is NOT because the person was a bad person. It usually is because the person was being rewarded for breaking the rule.

WHAT! We don’t reward people for breaking rules! Well … maybe you do.

Rewards for Breaking Rules

rewards

What kind of rewards could the electrician get for skipping the lockout/tagout?

  1. The work is easier.
  2. The boss is happy when the work gets done quickly.
  3. The electrician’s reputation increases because he is known for “getting things done.”
  4. Maybe he gets off early by completing the job quicker.

Those are some examples of rewards. Notice that they all are pretty certain, happen really soon, and are all positive.

Disciple

On the other hand, what happens if the electrician gets caught taking a shortcut?

Well, that is pretty unlikely. No one is out there where he is working. (No operators or supervisors.)

Often, if you get caught and it is just your first offense, you just get a warning … or maybe the operator or supervisor that catches you doesn’t even say anything because … everybody takes shortcuts. After all, that’s the way we do things around here.

Of course, there is always the chance that somebody could reset the breaker and the electrician could get electrocuted. But that’s not going to happen. After all, who would mess with the breaker box?

The worst that could happen is that the electrician would be disciplined for taking a shortcut. But the electrician is known for being a hard worker. The bosses like him. He would probably just get a warning. (Counsel the electrician to be more careful and not take shortcuts with lockout/tagout.)

If the electrician got fired, everyone would think that was unfair. He didn’t even get a warning (per our progressive discipline policy). And he was just doing what everybody does to get the work done.

This Never Happens

You may think:

Undeserved blame seldom happens.

Oh really? Look at these examples of blame (discipline) and see if you think that someone might cover up a problem after they saw what happened to these folks…

Eric Cropp

A pharmacist goes to jail for failure to catch an error:

http://doctorrw.blogspot.com/2009/11/eric-cropp-second-victim.html

The governor reacts to a bridge collapse … will people cooperate honestly?

https://www.taproot.com/miami-bridge-collapse-is-blame-part-of-your-investigation-policy/

A Commanding Officer, Executive Officer, and Command Master Chief are blamed and disciplined for a collision at sea:

https://www.taproot.com/us-navy-7th-fleet-announces-blame-for-crash-of-the-uss-fitzgerald/

Or how about these criminal charges after a flood:

https://www.taproot.com/criminal-charges/

Doctor goes to jail

Or how about a Doctor in England being sent to prison for a mistake and delayed care (and later found not to be at fault)?

https://www.taproot.com/the-blame-culture-hurts-hospital-root-cause-analysis/

And that’s just five examples. If you read this blog, you have seen dozens of articles about people being blamed for accidents that were set up by traps in the system.

Is Blame Built Into Your System?

Some root cause analysis systems even have blame built into them. Blame that can cause an accident. Here are some examples of cause categories in blame oriented root cause systems:

  • Attitude
  • Attention less than adequate
  • Individual’s capabilities to perform work less than adequate
  • Less than adequate motor skills
  • Inadequate size or strength
  • Poor judgment/lack of judgment/misjudgment
  • Reasoning capabilities less than adequate
  • Lower learning aptitude
  • Memory failure/memory lapse
  • Behavior inadequate
  • Violation by individual
  • Inability to comprehend training
  • Insufficient mental capabilities
  • Poor language ability
  • Inattention to detail
  • Mindset

That’s just a short example – there are more! For an article about blame oriented root cause analysis, see:

https://www.taproot.com/is-blame-built-into-your-root-cause-system/

Once you read the article, you should be convinced you don’t want to use one of these blame oriented root cause analysis systems. (Check your system to see if it has blame categories.)

And if you don’t have a system and you just use cause-and-effect or 5-Whys, you also have a blame oriented system. These techniques often stop at blame for the root cause (and fix it with discipline).

Blame is so Pervasive, Some Make Jokes About It

If you really want a blame oriented root cause system, try this one:

blame oriented root cause analysis

It is either blame or hide the problem. The system above was given to me by a utility vice president. He thought it was funny.

Elvis sang about blame…

If you are caught in a blame oriented system, you probably need one of these…

Using the Peabody Foam Finger Pointer, you can shift the blame.

What Should You Do About Blame?

To start with, have your management read Book 1, TapRooT® Root Cause Analysis Leadership Lessons. The story of the Tale of Two Plants demonstrates three different visions including the Blame Vision. It’s a great way to get a discussion about blame started.

Then watch this video about an error in the hospital:

Second, see this root cause analysis success story:

Improving Investigations by Focusing on Fixable Causes Rather Than Blame

You can find the system causes of incidents and fix them to prevent future accidents. How?

TapRooT® Root Cause Analysis

How does that work? Here is a success story from a water company…

The TapRooT® System looks for system problems and helps you prevent accidents AND avoid blame.

But what if someone really should be blamed? There is a place for that too. But first, you have to prove that there wasn’t a system cause.

There are three TapRooT® Users presenting their best practices for stopping blame in a session titled: Defeating the Blame Culture, which is part of the 2021 Global TapRooT® Summit in Knoxville, TN, on June 14-18. That’s just one of the many sessions you will find helpful. See the complete Summit schedule at this link:

https://summit.taproot.com/schedule

Learn More About a Non-Blame Oriented Root Cause System – TapRooT®

Read more about TapRooT® Root Cause Analysis here:

https://www.taproot.com/taproot-advantage/

or download a white paper about the use of TapRooT® Root Cause Analysis by clicking on the document below:

TapRooT® ®

Learn more about training to teach you to use the TapRooT® Root Cause Analysis System by clicking on the link below:

https://www.taproot.com/solutions/rootcausetraining/

And see the dates and locations for our Public TapRooT® Root Cause Analysis Training at THIS LINK.

TapRooT® Training

Would you like more information about holding a course at your site? Contact us by CLICKING HERE.

Categories
Accidents, Human Performance, Investigations, Patient Safety & Healthcare, Root Cause Analysis Tips
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