Many safety professionals may be supporting the proliferation of blame without knowing it. As we have found success in removing blame from the frontline operators, we have unintentionally redirected blame at the operational systems in which people work and their upper management. This needs to stop. The field of safety has come a long way in supporting frontline staff and taking a systemic focus on safety. This is of course supported by prominent works such as Behind Human Error which guide safety professionals to see beyond the human contribution and seek out the complex systemic influences behind it. Unfortunately, I believe we have been communicating an unintended message that blame should be shifted up towards organizational decision makers and the systems people work within.
While I am in full support of removing blame from frontline operators, I believe there are unintended consequences to allowing blame to then be placed onto other components of the system. These unintended consequences include strained relationships between workers and management and disdain for the organizations in which people work. Ultimately, this may lead to decreased trust from frontline operators and decreased satisfaction with their workplace. These are a few considerations for safety professionals to avoid this shift:
Emphasize that organizational leaders are well intentioned
As David Woods would say, “systems work as designed, just not how the designer intended.” Working with many leaders throughout different agencies, I am yet to encounter a leader that does not care about their staff. Without a doubt, leaders are continuously trying to do what they feel is right. This connection needs to be made to organizational staff and oversight bodies.
Safety professionals need to communicate that organizational leadership want to improve and support their staff better. We need to extinguish the notion that the agency’s leadership is selfishly nestled in the white castle on the top of the organizational hierarchy. Instead, leaders need to be provided with the frontline perspective. As stated in a previous post by Ron Gantt, the role of the safety professional is to make these connections. They also need to provide leadership and management with the right tools and strategies to improve their organizations in restorative and just way.
Acknowledge shared systemic constraints
Mapping out systemic influences to adverse events, I have seen that similar pressures and constraints exist throughout the organizational hierarchy. While frontline workers may be influenced by bureaucratic demands for efficiency (e.g., production quotas, deadlines) so too are agency leadership. Different regulatory bodies may have demands that agency leadership must meet (e.g., metrics tied to funding, legislative accountability). We need to give credit to the pressures and limitations existing throughout the entire system.
Safety professionals must communicate that limited time, insufficient resources, fear of failure and competing goals are not only the norm for frontline operators and are also affecting agency leadership. Additionally, these shared pressures are deeply intertwined in the organizational ecosystem. This approach can support a more united front in managing these pressures without losing focus on how they influence work at all levels of the organization.
Highlight that a systems approach is not binary
Too many times I have heard the phrases, “it’s not a human problem it’s a system problem,” or “the problem isn’t with the frontline it’s with the management.” While it emphasizes that issues are not isolated to the sharp end operators, it may maintain the reductionist view that it is another component of the system (e.g., leadership, training system, policy system) that is at fault. Instead we need to emphasize that different components of the system are well intentioned.
Safety professionals must emphasize that systems are not binary and do not exist in exclusive states (e.g., frontline v. management, human v. system). Rather the emphasis needs to be placed on the fact that organizations are complex and interdependent. While different components of the system are influencing actors at play in a sociotechnical system, they cannot be understood in isolation. Rather we need to study these interdependencies to understand underlying systemic issues and proactively address them in a prospective way.
Give credit to collective accountability
Fragmented problem solving rarely solves the ever-present issues existing in sociotechnical systems. Agencies find success with top to bottom alignment in efforts toward shared goals. Additionally, this collective approach breaks away from the fallacy that failures are isolated to component parts of a system. Instead we need to promote the strength that comes with united efforts of change.
As safety professionals we need to emphasize that our intent is not to create factions within agencies. The progression of safety and system improvement may be unattainable without mutual effort. There needs to be emphasis on shared accountability, for instance the accountability of staff to identify vulnerabilities and the accountability of agency leadership to support mitigation.
The use of blame in safety management needs to be removed all together. The backward looking and reductionist application of blame does not give credit to the infinite complexity of sociotechnical systems. The focus needs to be applied to a forward looking accountability. As introduced by Virginia Sharpe, this prospective approach to accountability places emphasis on learning and improvement. It emphasizes that frontline operators should be accountable by providing their input on how adverse events occur and can be avoided in the future. It also emphasizes how management should be proactive in making needed improvements. Ultimately, the collective efforts of the organization need to be focused on restoration and not retribution.
Great extended thinking piece Noel. As an interesting experiment I’ve used in the past is utilizing ‘just culture’ flowcharts for unintended events within senior management teams which has improved their understanding of operating and leading within complex socio-technical systems – Largely so they understand managing trade-offs yet at the same time in a system which they are held accountable in a binary manner.
I love the below in a similar vein from a TED talk re: Complexity / Complicatedness and driving forward looking accountability. “The CEO of The Lego Group, Jorgen Vig Knudstorp, has a great way to do this. He says, blame is not for failure, it is for failing to help or ask for help. It changes everything. Suddenly it becomes in my interest to be transparent on my real weaknesses, my real forecast, because I know I will not be blamed if I fail, but if I fail to help or ask for help. When you do this, it has a lot of implications on organizational design. You stop drawing boxes, dotted lines, full lines; you look at their interplay.”
Reference: https://www.ted.com/talks/yves_morieux_as_work_gets_more_complex_6_rules_to_simplify?language=enign. You stop drawing boxes and creating dotted lines. You look at the interplay”
Thanks for this insightful post Noel. I can relate to your points from the perspective of investigation methods. Methods based on the Swiss Cheese Model tend to shift the focus more towards the blunt end and they do that using the associated language, such as errors, deviations, etc. Blame is then the most logical consequence and that indeed doesn’t help us.
The local rationality principle can help us in this respect because we should use this for every person involved in the organisation. Leader and managers also have a specific situation and context to deal with that includes uncertainty, ambiguity, trade-offs and other complexities. Your 4 ways can help us to indeed focus on gaining a rich understanding of the system without appointing blame.
Blame; if you really want get to the core level is our whole culture. Safety mostly fails because we have priced ourselves out of practicing safety to level expected. Organisations are expected to make profit, but consumers (you) do not want to pay high prices, so to make a profit things have to be lax…that is often safety.
It is flow on effect and society do not want to take on the blame, so we do nothing and pass the ownership down the line.