May 10, 2023 | Ken Reed

Is Blame Part of your Culture?


We often see companies who seem stuck in various types of blame cultures.

I’ve observed several different versions of blame:

  • A company leadership that blames employees — blame is the operative action in resolving an incident/error
  • Employees blame leadership
  • Adversarial company components (union vs. management, doctors vs. nurses)
  • Legal (company vs. plaintiff)
You did it

There are many other examples, but you can picture how different internal company cultures or organizational strategies can breed a blame mindset. Say, a company might be trying to protect a particular group, or maybe assign blame to a different group. Often it is done without any forethought or intentional bias. It is just how some companies operate.

It can be difficult to move beyond these types of cultures. This mindset becomes ingrained. Fear becomes the dominant emotion when something bad happens. While almost all of us want to prevent bad things from happening in the future, the fear of retaliation, blame, or loss of profits can cause us to sideline our better judgement and focus on shifting blame to a suitable target. Once this mindset is firmly established, abolishing it can be a tough nut to crack.

Changing a blame culture will normally take a multi-pronged approach.

You have to attack the problem from many directions:

  • Management has to be committed to removing blame
  • Employees have to believe in this commitment
  • Internal strategic groups (union/management) have to possess/develop trust and understanding in the motivations of “the other side”

None of these are easy to overcome. However, one of the very first, most basic pillars of this culture change has to be a method to find root causes of problems without finding fault.

The understanding that humans, in general, want to do a good job should be a basic tenet to any investigation.

Very few people wake up in the morning and say, “I can’t wait to get to work today. I think I’ll stick my hand into a pinch point and get hurt.” So, when this does happen, we need to be able to dig into the reasons that people make these poor decisions. Just blaming the employee (“Counseled the operator on the importance of keeping their hands out of pinch points”) is pretty useless and is actually counterproductive when trying to establish a good company culture.

Very few RCA systems have a method to dig to this level. Almost all RCA systems I’m familiar with stop at the “mistake” level. Do these “root causes” sound familiar?

  • “Mechanic did not follow the procedure, in that . . .”
  • “Pilot turned the wrong switch”
  • “Operator turned off the wrong pump”

With these types of “root causes,” you can already see the terrible, blame-oriented corrective actions that will result. Why do most RCA systems get stuck at this level?

We’ve found that most RCA methodologies rely on the innate knowledge of the investigator. Sometimes investigators use a rudimentary set of categories that are based on blame. Some just hope to get a bunch of smart people together and hope they are somehow experts in human performance. They do not have an expert system that guides them to human performance-based root causes. There is no consistency in the results. Ever try to give a 5-Why investigation to 3 different groups? They all get different answers. Why would we trust those types of results?

That’s where TapRooT® Root Cause Analysis comes in. The TapRooT® System is designed to get your investigators to the same root causes that a trained human performance expert would have gotten. It provides guidance in the questions they should ask to make sure nothing is missed. It does not focus on mistakes; it ensures that your investigators are digging to understand the reasons people make bad decisions and mistakes. We no longer have root causes that are designed to blame the employee.

The end result? Corrective actions are now focused on the human performance problems that our companies have control of. We can apply corrective actions targeted at the reasons humans make errors, not the errors themselves. Your employees will see fixes that are making it easier to do their jobs correctly, eliminating the reasons for the initial errors. Blame goes away. Trust is built and maintained.

I encourage you to take a look at your root cause and corrective action systems. See if you are perpetuating a lack of trust in both your leadership teams and the deckplate employees, or if you are on the path to eliminating blame and building trust across your organization.

Operational Excellence, Root Cause Analysis
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