Removing Blame From Your Investigations

I should stop reading so many LinkedIn posts. It gets my blood pressure up when I continue to see someone post a safety issue (especially a “funny” video), and then I see all the blame comments start showing up:

• “Darwin Award winner”
• “What an idiot.”
• “They needed to pay more attention.”
• “Glad that guy doesn’t work for me.”
• etc. ad infinitum

Today, instead of trying to explain why human performance investigations should stay away from blame and these useless comments, let me give some advice on where we can easily and effectively work to actually remove the blame from our investigations. Here are 3 places to concentrate:

1. In the Beginning…

To avoid blame, the first place to put your emphasis is at the very start of your investigation. The evidence collection phase is where blame will first start pushing its way into your results. It’s where investigators start asking a few very basic questions, based on their own level of knowledge, biases, and limited experience. It’s where I see a great opportunity to remove blame, but instead, where those first indications of fault start showing up. Our investigators don’t know what questions to ask, so they just ask the questions they are familiar with, often focused on a narrow range of experience.

I sometimes hear that we “just need to get a smart group of people together to ask questions.” While this can certainly help, I’ve found that these “smart people” just don’t have the range of expertise needed to ensure they aren’t missing anything. How many of your team members understand human performance? Do they understand how the wrong color label can cause issues? Do they know what proper tone an alarm should have to make it readily noticeable? Or will we just default to “The operator was not paying attention to the alarm” as our issue? These types of things will almost certainly be overlooked, even by a group of “smart” people. They just don’t have the training or experience needed to find these kinds of problems.

This is where a structured process, which includes human performance expertise, can help ensure you are asking all the right questions and aren’t missing anything. It will also ensure you are staying away from just blaming your employees for the issues.

2. Analyzing Root Causes

Our next opportunity to avoid blame is to quickly dig down to the actual root causes. Most “root cause analysis” systems seem able to identify a human error (“Operator did not turn off the overheated machine”), but then stop and leave it here at this blame level. They don’t make sure we understand the human performance issues that might have led to someone missing an indicator or not completing a required action. This is where blame quickly presents itself unless your team just happens to have some human performance experts involved.

Your investigation process needs to provide human performance guidance, built right in.

3. Corrective Actions to the Rescue

Once you collect the correct data and then do a solid root cause analysis, you must now ensure that bias and blame don’t worm their way into your corrective actions. It’s too easy to just think that the operator screwed up, and we can fix that by reminding, reinforcing, ensuring, etc. These are mostly pointing at the person again, when what we really want to do is fix any problems in our systems that were allowing the mistakes to occur. There are a few things we can do at this point to avoid injecting blame on the back end:

• Make sure all of your corrective actions are targeted at one or more of your human performance-based root causes. When we add “extra” corrective actions that are not pointing at root causes, they are almost always blame-oriented.
• Your corrective actions should lean more toward engineering controls (remove the Hazard, remove the Target, make it easy to do it right, etc.), not default to training and supervision. These categories are very often just blame in disguise (“Retrained the operator on the importance of maintaining vigilance while monitoring their panel”). Not only are these focused on the individual, but they are also just very weak actions on their own.
• Your corrective actions should concentrate on system weaknesses that allowed smart people to make those errors. Just correcting (blaming) the person leaves the poor systems in place that allowed that error to occur.

Blame has no place in our investigations. Make sure your investigation processes focus on true root causes and not on the employee. That will give you much more effective results, both for your employees and your company as a whole.

If you want investigations that move beyond blame and consistently deliver real system improvements, formal training matters. Register for an upcoming TapRooT® Root Cause Analysis Course to learn a structured, evidence-based approach that builds human performance thinking directly into every investigation.