Stopping the Blame Game in Safety Incidents
Organizational learning is a key success factor for improving safety and reducing the probability of incidents. Insight into the quantity and nature of incidents and deficiencies in general is prerequisite to organizational learning. For employees to report on such occurrences there must be a ‘just culture,’ where issues can be discussed freely and underlying causes investigated and corrected without fear of punitive actions. This paper focuses on the relationship between blame and just culture and safety, and what is necessary to change from a blame culture to a just culture.
Improvement in the organizational learning process is necessary to reducing the probability of incidents. Unfortunately, many organizations can be characterized as ‘blame cultures,’ where individual blame for human error is over-emphasized, at the expense of correcting defective systems. This blame culture strongly interferes with the improvement cycle.
Organizational learning is seen as one of the most important factors influencing organizational safety. The process comprises five steps.
Intuiting. Recognizing a pattern or possibilities, which is embodied by an individual recognizing an incident
Interpreting. The individual shares the insight with others, and eventually the individual or someone else reports it to the official reporting system.
Investigating. Determining what exactly went wrong, and why
Integrating. Sharing knowledge at the group level.
Institutionalizing. Transferring the insight into rules, systems, or routines at the organizational level and adjusting the system to reduce the probability of future similar incidents
The system can be further adjusted when there are still unsafe working conditions by repeating the process.
To report incidents, there needs to be willingness and the requirement to report. Employees may be unwilling to report for reasons such as believing it will not make a difference, fear of legal consequences, or perfectionism. Investigation may be hampered because it is time consuming and costly. The extent of blame or just culture in the organization is very important to the success or failure of organizational safety.
Just and Blame Cultures
To understand how to shift from a blame culture to a just culture, the mechanism behind the blame culture needs to be understood. By understanding this mechanism, crucial points of action can be discovered and effective interventions developed. One definition of blame culture is, “a tendency within an organization not to be open about mistakes, suggestions and ideas, because of a fear of being individually held accountable for them.” J.T. Reason, one of the first to mention blame culture, argues that the high amount of individual autonomy in Western cultures contributes to the development of a blame culture. When something goes wrong, people are expected to be individually responsible. This produces a habit of searching for a culprit to blame when incidents happen. When blame is prevalent in the workplace, this will reinforce it because, when an employee is blamed, he or she will try to protect his or her self image and avoid blame by blaming someone else. The goal of protecting one’s self image is easily adopted by colleagues and rapidly spreads a culture of blame. A blame culture also can be prevalent without employees explicitly blaming each other; the fear of being blamed is just as effective in constituting this culture. The onset of blame culture can be as early as during the education stage, since this education often is focused mostly on increasing performance instead of increasing safety or organizational learning. Employees are taught to make no mistakes, but rather to show a degree of perfection in their work that is almost humanly impossible. This may lead to a fear of taking responsibility for errors, which in turn enhances blame culture.
When an incident occurs in a blame culture, the focus is on who caused the incident instead of the system that might be unsafe. Attention is thus drawn away from the cause, and the system is not improved. Responses such as disciplinary actions and cautionary tales tend to demoralize employees and reduce health and well being. As workers try to protect themselves and blame others, their attention shifts from safety to unnecessary actions such as completing irrelevant paperwork. Blame culture also contributes to the avoidance of taking controlled risks necessary for one’s job as a way of avoiding damage claims. The time and energy devoted to these negative consequences would be better directed toward analyzing errors and learning from them.
Generally speaking, a just culture is a supportive environment in which concerns or dissent can be expressed and mistakes admitted without suffering ridicule or punishment. In this culture, incidents are identified, reported, and investigated to correct the system. Incidents are seen as system failures that teach important lessons to the organization.
Where blame culture inhibits organizational learning, just culture enhances it, and fear of blame is replaced by the ability to be held accountable for mistakes. Employees stay precise and alert in their work, without letting the fear of being blamed for mistakes get the best of them.
Measuring the Cultures
Although there is a wealth of literature about blame and just culture in a qualitative sense, there is no clear view of the exact constructs characterizing just and blame cultures, and no tool to measure the amount of blame culture. A literature overview of more than 110 peer-reviewed papers on blame and just culture published after 2000 revealed that the concepts are multifactorial and consist of a range of subconcepts, or components, that can be measured using checklists taken primarily from patient safety literature, where this topic has attracted much attention in the past decades.
Nine components based on the frequency of mentions found in a literature overview of more than 110 peer-reviewed papers published after 2000. These are discussed in paper SPE 190594.
For each component, validated checklists were available in the scientific literature to measure the prevalence; these were combined into a single survey. The survey contained questions related to the nine components and the first two steps in the Learning from Incidents (LFI) process. The questionnaires were checked for construct validity, and correlations with just culture and other components were calculated. Questionnaires were issued to employees of a Dutch subsidiary of a global construction company. More than 300 employees at all levels of the organization completed the survey.
The results confirmed the relationships between the various components and just culture and reporting of incidents and learning from incidents. Higher scores on the just culture scale correlated to higher reporting and deeper analysis of incidents. It was also shown that the components themselves are highly intercorrelated, confirming predictions from the literature review. None of the components had a perfect correlation with just culture, and there was no single ‘silver bullet’ to fix the blame culture in an organization. The long and winding road to just culture involves making changes on a range of organizational characteristics. The most promising aspects are psychological safety, trust, and openness. These three components are the closest related to just culture and have the strongest connections with the other components. They comprise the first two steps in the LFI process. By focusing on them, not only is the level of just culture increased, but also, the ability to learn from adverse events is positively influenced.
The results of this research allow organizations in a range of domains to diagnose their current position on the blame-just culture spectrum by conducting a survey among all employees. From this, they will be able to embark on efficient and effective steps on the long and winding road toward a just culture. They can build a business case for improvement, prioritize their actions, and effectively intervene and evaluate the effect of interventions on just culture and relevant primary process and output indicators. This will be a major step forward in the reduction of the probability of adverse events, and can help organizations achieve their ultimate goal of zero incidents.
Change in culture alone will not improve safety, but a just culture will improve organizational learning capabilities, and that can lead to implementing more effective actions. As such, it can provide a sound basis for a further reduction of the number of incidents to the ultimate goal: zero.
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18 June 2019
19 June 2019