By Phil La Duke
What is it about blaming that feels so good? Why do we enjoy it so much? What’s that? YOU don’t enjoy blaming people; I’m sorry, I’m skeptical. I have reason to be. As a certified Just Culture practitioner who studied under David Marx (author of the book Whack A Mole and self-proclaimed “father of Just Culture”), a seasoned consultant in organizational change initiatives aimed at safety, and an obnoxious blogger who is seemingly pen pals with every kook and safety whack job, I see a lot of people who can’t wait to blame; from “stupidity” to “the culture” if its one thing the safety industry isn’t short on, its blame.
Blame satisfies a visceral and deeply ingrained need in people; it makes us feel as if some sort of justice has been meted out. When we find the person or persons responsible for something we can shout “aha! We’ve caught you”.
Just Culture And Blame
Just Culture, more a corporate governance system than a safety methodology, doesn’t believe in blame. Instead, Just Culture teaches that there are three basic kinds of human behavior: human error, at risk behavior, and recklessness. Human error are those good old fashioned “honest mistakes” that everyone makes at one point or another (in fact, a researcher I once saw speak at a medical conference, said that the average person makes five mistakes an hour, and if anyone out there can find the source of this research (my notes were literally destroyed in a flood) and send it to me you will have my heartfelt appreciation)). A mistake, in Just Culture terms, is any undesired unplanned outcome. Some believe that mistakes are our subconscious minds way of testing the safety of rapid adaptation—that our brains deliberately, albeit subconsciously, cause us to err as a sort of experiment to see how safe it is to adapt. At any rate, if the mistake isn’t deliberate it is unjust to punish those who make them. (That’s not to say that one isn’t necessarily accountable, but we’ll get to that in a moment.) Just Culture teaches that we should console the mistake maker instead of scolding, or worse yet subjecting them to a corporate disciplinary action. Consoling someone for making mistakes sounds a bit warm and fuzzy, and it seldom satisfies people’s thirst for blood and blame. Someone has to pay for the wrong that has been committed. I taught Just Culture in healthcare and I was taken aback at how, sometimes decades after a lethal mistake, people would carry the sense of guilt, shame, and sadness over a mistake they had made that killed or crippled a patient. Even so, many of us wouldn’t condone the killer (however accidental) of one of our loved ones being consoled. No, we want to blame them; we want them to pay for what they did, even though cognitively we know that they can never pay enough to satisfy our bloodlust. Worker safety, at least in terms of mistake making, is similar to patient safety, if a worker forgets a critical step and causes a serious injury or fatality we too often judge the worker as either irresponsible or just plain stupid. We seldom allow that mistakes happen, even though there but for the grace of God go any one of us; no, others must be blamed. They must be judged and punished. We demand perfection from everyone but ourselves.
The second behavior, at risk behavior, also often produces a catastrophic outcome. We see this all the time in safety; someone takes a shortcut, ignores a safety procedure or requirement, or simply decides that in this case the risk of injury is minuscule compared to the rewards associated with taking the risk. The temptation to blame is far stronger now, we get angry because in this case, he or she KNEW better but decided to risk it anyway. Surely we must blame SOMEONE, we can’t just throw our hands in the air and say “Oh well, (expletive) happens”. No, clearly someone must be held responsible. In these case our bloodlust can whip us into a frenzy, driving us to type out angry missives in online threads that only a handful of people will read and about which far less will care. People will rail against the molly coddling of the guilty, and spit venom at those who dare try to deflect the blame onto society, or the system, or…whoever. Unfortunately, we need workers to take risks. Calculated risks, well-thought out risks to be sure, risks that are proportionate to the rewards, but risks none-the-less. Our policies and procedures can only govern about 75–80% of the situations workers will face, and we want them to show sound judgment when confronted with situations that are outside the policies, in other words, we rely on them to take risks. We can’t expect people to take some risks and blame them for the outcomes. Under a Just Culture system at risk behavior would be trained and coached; we want people to take risks, but we want them to do so wisely.
The final behavior is recklessness, which is defined in Just Culture, as a behavior where the risk is so out of proportion to the reward that a reasonable person would judge it to be unjustifiable. Neat definition, but so subjective that one man’s recklessness is another’s reasonable risk. Even here a Just Culture system wouldn’t blame the reckless, they would simply be disciplined; probably harshly.
Where’s the Danger In Blame
Blame shuts down conversation and investigation. Continuing to research solutions after one has assigned blame is like continuing to look for your car keys once you’ve already found them—where is the point in continuing to ask why things went sideways when you already know who did it? In the cosmic game of Clue that is incident investigation, no one ever asks WHY Colonel Mustard did it in the Conservatory with a Candlestick, once the answer is revealed the mystery is solved and the game is over. So too is the case with blame; once we’ve assigned it we can punish and shame the guilty and go about on our merry way. At least, that is, until the next time.
There’s another, larger, danger in blame. I don’t know who said it, or even the exact quote, but someone (perhaps me) said that errors plus blame leads to criminality. If we face blame and punishment we tend to conceal our culpability; we make excuses, we lie, we cover things up. Nothing gets solved. No actions are taken to fix the system problem and the hazards lurk unseen and undetected until something so horrific and catastrophic happens that concealment is impossible, blame avoidance ends up killing people leaving us with no one to blame except the dead and dying.
 Source: my anus; I made this statistic up, but until someone gives me a fat government grant to scientifically study the issue I’m afraid it will have to do.