This subject can get very opinion-related very fast, so I will be as objective as possible. I always wondered why (in the past) an operator can leave a valve out of position with no consequence and have no investigation or punishment from the action, and then the same or different operator leaves the same kind of valve out of position under similar circumstances with an undesired consequence, and the individual gets time off. When this actual situation crossed my path in the mid-90s I challenged a leadership team member as to why they felt this course of action was appropriate. The manager told me the individual should have been paying attention more based on the risk or opportunity for greater consequence. Doesn’t that sound like an old-school version of Human Performance? Blame the individual and then we’ll figure out some corrective actions to support the investigation. Who is paying attention to the system that potentially caused the mis-position in the first place? Back then where I worked, only one operator was performing manipulations without concurrent (or even independent verifications). The entire system wasn’t being looked at for opportunities of failure.
Click here for a sad story about a building inspector who thought he made a mistake and blamed himself prior to understanding all of the system.
Click here to see Sidney Dekker’s book on “Just Culture”
Click here for one of my new favorite books (thanks to Kay) on why we blame, “Whack-a-Mole,” by David Marx.
How can Jenga explain Latent Organizational Weaknesses?
A really cool way to think about this was explained to me last week from a Bechtel Human Performance Instructor, who I will be interviewing one day on the podcast (you’ll get to meet her – she’s awesome): She likes to use the built Jenga tower to model the system of work, and then has students identify failures within the system and pull blocks out representing each failure. Ideally, the tower still stands and then after a bunch of holes are now visible to everyone, she asks the group to look at it from the top down. You cannot see all the latent organizational weaknesses and everything looks good. If everything looks good, it must be the last person to touch it, and that is how way too many people are perceiving human error: looking at it from the end and not the side.
Click here for a funny example to consider – gotta love that BBT group. Who should be to blame for this Giant Jenga tower falling? It’s so easy to blame the last person to touch it. Oh wait, blaming isn’t what we do – understanding the flaws in the system that need to be more robust prior to the tower falling – that’s something we do.
What is punishment?
I heard this within the past two months, and sincerest apologies to the source because I cannot remember where, but it stuck with me. Punishment is anything that distances the worker away from the work. Pretty profound, right? Examples can include: unpaid (or even paid) time off, loss of qualifications, removal from job, transferred to another department, etc. Some people call this discipline, but in any forum we can probably agree it is still forms of punishment.
Putting it all together
Our culture has drifted into this seek first to blame philosophy, so thankfully, investigators are trained to hold biases aside and develop conclusions based on facts while considering the entire system. Withholding blame until latent organizational weaknesses (and other precursors) are uncovered and understood is key to driving an improvement culture, instead of one wrought with blame. This leads to the very important saying, the punishment must fit the crime, and rarely did someone make a mistake on purpose, so we must be very careful when we take a worker away from the work they do.