We Need To Get Out of The Business Of Blame and Shame


By Phil La Duke

Several weeks ago I began exploring safety as an outcome, as the product of well-managed business systems and not something that needs to be managed as its own element. The business systems I identified were: competency, process capability, hazard and risk management, accountability systems, and engagement. In subsequent articles I explored competency, process capability, hazard and risk management, and today I sat down to the keyboard intending to write about one of my favorite accountability topics, Just Culture. But as I ruminated on the topic I realized that what I really wanted to say transcends Just Culture.

For the uninitiated, Just Culture is a management philosophy designed to hold people appropriately accountable. According to one of the current thought leaders in Just Culture, (and author of the book Whack A Mole) there are three basic kinds of behavior: human error, at risk behavior, and recklessness (I became a certified Just Culture practitioner by studying under David Marx, and you can argue that carelessness is also a behavior, but David will argue longer until you give up and just accept these three. Trust me David is a lawyer and he is one hell of an arguer.)   So in begrudging deference to David, I stick to three. The larger message of Just Culture is that blame is a counterproductive and useless exercise that feels good but doesn’t really accomplish much except to piss off the people being blamed and make them defensive. If we take a look at the three behaviors, only recklessness deserves blame and shame. Someone, I honestly don’t know who, said, “error plus blame equals criminality” and that is the reason that Just Culture and a blame free response to foul ups is so important. Just Culture gained real traction in industries where blame was so pervasive that people would conceal their mistakes and hope for the best—no such a bad thing if you are painting a barn, but if you are administering medical treatments or flying an airplane the smallest oops can have dire consequences. If a nurse knows, for example, that she (and sorry for sounding sexist but nursing is still predominantly female and besides it’s my example so if I want to make it a female nurse or a hermaphroditic orangutan that’s my business, if it upsets you tell your therapist) has accidentally given the wrong medication to a patient and if she admits her mistake she will be fired, there is a good chance that she will at least be tempted to say nothing. (The orangutan isn’t going to say anything either but hey, someone should have thought twice before putting it in charge of administering meds). In high consequence industries where the tiniest mistake can kill people blame conceals the errors.

But I digress, as I said, I didn’t want this to be yet another column about Just Culture. It just strikes me as odd that we as a profession continue to extoll the virtues of a blame-free workplace and the wonderful opportunity we have to learn about the causes of injuries while promulgating blame-based systems out of the other side of our mouths.

Blame-Based Safety

A friend of mine is a columnist who is an outspoken critic of BBS. One of his chief criticism is that BBS systems tend to blame the worker. The BBS fanatics all try to shout him down (good luck, the guy cut his teeth at Dow, is a PhD with actual work experience, and literally has forgotten more about safety than most people (including and perhaps especially me) will ever know) but he is right: Behavior Based Safety tends to lead to a climate of blame and shame. Oh, to be sure the purveyors of snake oil will assure you that THEIR brand doesn’t blame the worker, but I have found that these systems, whatever their intent, lead to a climate of blame. If the intent is not to blame workers, when one begins with the assumption that the incident is the result of behavior on the part of someone, and in most cases that someone is the injured worker, it is impossible for the injured party to feel culpable.

Even something as simple as behavioral observations can create a climate of blame. Whenever someone stands in judgment of us it is only natural to feel defensive. But my intent is not to create another angry argument for or against BBS, because quite frankly there is a whole new trend toward blame-based safety, which holds that leaders are to blame for injuries. In there acts and decisions, in what they done and what they have failed to do. While there is no small benefit in drawing leadership’s attention to the role they play in worker safety, the time for accountability is before people get hurt.

I have said many times that everyone plays a role in safety, but too often we only hold people after someone has been harmed or property has been damaged. People need to be answerable for ensuring the workplace is free of hazards, for the decisions they make, and for managing one’s performance inhibitors (the things in one’s life that make human error and unnecessary risk-taking more common like stress, lack of sleep, drug or alcohol use, etc.).

Blame remains a pointless exercise because once we have determined who’s at fault there is no reason to look further (it’s the same reason your lost car keys are always the last place you look.) That’s not to say that people shouldn’t be held accountable, but people need to be held accountable for their actions irrespective of the outcome. This is a basic tenant of Just Culture that the extent to which one is accountable is independent from the outcome. Actions taken and decisions made in good faith are not punished no matter the outcome and recklessness is subject to discipline even if no harm occurred as a result. It’s a bitter pill for some to swallow, but swallow it they must.