October 2, 2008 | Mark Paradies

Stop the Management Blame Game

What’s the first question asked after a major plant upset, a major injury, or another major oops?

Who did it?

Discipline is often dished out before a root cause analysis is completed.


Lt. Col. Ralph Hayles, a victim of this blame game after a military friendly fire accident, told attendees at the 2008 TapRooT® Summit that rapidly placing blame for an accident at a low level in the organization is a protective response by the organization and senior management. Doing otherwise allows outsiders to suggest that the organization or management needs to change (effective corrective actions). That could lead to blame for senior management. Blaming senior management could lead to organizational turmoil and failure to achieve the organization’s mission.

For example, after the accident that killed 15 people at BP’s Texas City Refinery, management fired five operators/supervisors because they didn’t “follow procedures.” Never mind that the procedures were almost unusable, there was a culture of taking shortcuts, the plant’s instrumentation was faulty, the mechanical condition of the plant was poor, and needed safety upgrades were long overdue. If high level management causes (such as cultural issues and insufficient budgets) are identified, that reflects poorly on the entire organization – right up to senior management! This could cause wholesale replacement of the senior management team and the requirement for major capital investments in refinery upgrades around the world. Therefore, the initial management reaction is to blame someone low in the organization.

Of course, blaming and disciplining a low level employee doesn’t fix the problem. The root causes go uncorrected. Future problems are assured.

What should be done?

Management must resist the blame game.

They must insist on real investigations, root cause analysis, & effective corrective action that cause organizational improvement.

Truly effective management goes one step further. They become proactive and invest in improvement to prevent accidents.

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Root Cause Analysis
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