Stop Playing the Name, Blame and Shame Game in Incident Investigations

In our second guest post of Incident Management Month 2018 #IMM2018, author and EHS expert Wilson Bateman argues the frailty of the Name, Blame and Shame Game in incident investigations.

“A close one!” “Close call”, “Near hit”, “Near miss”, “A lockout violation”, “Serious Injury & Fatality (SIF) issue with numerous employees involved”, “It could have been bad”, “Multiple fatalities” – No-one wants to read these headlines, never mind experience them.

Some people consider a close call to be a free lesson and a chance to look at the safety management system. This is not always the case. Sometimes, a close call or incident is followed by “The “2nd Incident”, or as I call it, the “Name, Blame & Shame Game”. In other words, a quick fix, throwing someone under the bus, safety cover-up, white wash, a conspiracy of sorts, usually with good intentions. In this type of incident investigation, someone must be blamed because corporate wants a resolution. It’s as old as time itself, but rarely is it ever effective.

The Name, Blame & Shame Game

Incident investigations sometimes follow the “train, discipline, and terminate” model. The problem with this is that the analysis is not complete and therefore the incident has not been properly resolved. In these cases, the supervisor might be terminated, several employees disciplined and the team re-trained. This model is often referred to as the “fix the worker” model.

Thin Slicing in Incident Investigations

Thank you, Malcolm Gladwell, for developing the term “thin slicing”. This term loosely means that quick decisions are made based on limited information. It is clear to see why this could be very dangerous, but I’m sure that we’ve all seen it. This is often true for incident investigation and analysis.

The lockout program may not be as robust as the company believes it is. We often think our safety initiatives are world class; the argument is sometimes made that we meet the legal requirements. While that might be true, here’s something to think about - so did the Titanic.

I often suggest that the law is the minimum standard. It’s expected that you will meet the requirements of the legislation. It is clear to see, upon reviewing many incidents, accidents and fatalities, that meeting minimum requirements is often not enough.

The “Name, Blame & Shame Game” often concludes the incident investigation, with no further thought being given to future incidents and preventing them. It also has many other negative effects on the safety management system and the culture within the organization. The “Name, Blame & Shame Game”? Now that’s thin slicing.

Can you create a list of the negative results that follow The 2nd Incident, “The Name, Blame & Shame Game”?

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(Exercise: The Self-Help Approach to Safety Excellence, 7 Safety Habits Book)

We need a new approach to incident investigation and analysis. The Name, Blame & Shame Game needs to be recognized and addressed. Think of a time that you used it yourself. Who have you blamed? Did it resolve the issue?

The Critical 7 (Part of Serious Injury and Fatality Prevention Program)

I am a fan of the Critical 7, The Cardinal Rules, Lifesaving Rules and the development of a Serious Injury & Fatality (SIF) prevention program. These models help to identify and create awareness around those activities that have the potential to contribute to serious injury. However, I am not a fan of the “Name, Blame & Shame Game” that is sometimes associated with the Critical 7.

I see incident investigation from a perspective of awareness and focus, not from the perspective of wanting to place blame. If you want to place blame, blame the system. Instead of “fix the worker”, why not take a “fix the system” approach?

Just for the record, I am not trying to diminish personal responsibility. It is true that we often need to address responsibility and accountability in incident management as part of the Critical 7 or SIF prevention. However, there is so much more to it than that. The previously mentioned process should not be about fear over losing your job, it should be about awareness and focus and working as a professional.

What are the Critical 7, Life Saving Rules or Cardinal Rules in your workplace?

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(The Self-Help Approach to Safety Excellence, 7 Safety Habits)

Common examples of a Critical 7 (Part of SIF Prevention) list:

Critical 7 (Low probability/High Consequence) SIF (Serious Injury & Fatality):

1. Fall Protection
2. Mobile Equipment
3. Lock-Out
4. Electrical Work
5. Safety Devices
6. Confined Space Entry
7. Excavation

(This list is only an example. Content varies depending on hazard assessment.)

What are the elements of your “Serious Injury & Fatality Prevention Program”?

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(The Self-Help Approach to Safety Excellence, 7 Safety Habits Book)

I often find when I ask these questions of employees, that they do not know the answers. What does this say about their safety management system and incident investigation?

Error Management Model

Let’s place our attention on the system first, then we can focus on the team. Yes, maybe the employee erred, but that’s only the beginning. Let’s face it, that’s what humans do, they make errors. It is what happens after the error occurs that is important. Maybe we need a new approach to error management as part of our incident investigations.

Let’s consider an aviation technique that is used to recognize and address error. The technique is called the “Sterile Cockpit”. Once the aircraft drops below 10,000 feet, the crew’s focus is restricted to landing the aircraft and nothing else; no talking or chatter of any sort unless it is directly related to the landing. Let’s call it an error management technique or countermeasure.

This technique helps to address H-FILES (Human Factors that Increase the Likelihood of Error) issues like stress and distraction in a proactive manner. What are your H-FILES (Human Factors that Increase the Likelihood of Error)? And what are your countermeasures?

The H-FILES approach works hand in hand with the Critical 7 and Serious Injury & Fatality Prevention.

My philosophy is Think Safety’s HARD (Hazard Assessment Risk and Duty). This is so important that it comprises the first chapter of my book 7 Safety Habits That Could Save Your Life. Nobody can ever say safety is easy. It requires constant attention and focus. Think Safety’s HARD encourage last minute risk assessment a tool to assist with decision making.

We need to continue our efforts to improve incident investigation and reduce serious injuries and fatalities by:

1. STOP the 2nd Incident, the Name, Blame & Shame Game.
2. Focus on the Critical 7 and Serious Injury & Fatality Prevention.
3. Develop Human Factors (H-FILES) and Error Management Models.
4. Promote Hazard & Risk Assessments.

The challenge is Serious Injury & Fatality Prevention.