The systems approach to learning why something went wrong (or went well) focuses on the interrelationship between four main system element categories: Management, Employee, Equipment, and Environment elements. Everything that happens at every organization, happens because of the way these elements work together. Good organizational learning practices will focus equally on each of these system elements in order to learn how this works and why sometimes things don’t work.
Todd Conklin and Bob Edwards teach us that blame is the enemy of organizational learning. It is often pointed out that blame halts any learning that could occur. But how do we know when blame is occurring? Focusing on each of these elements may put decisions made by individuals under the microscope. When those decisions are identified as errors, is that blame? I would answer with a “no.” Conklin and Edwards tell us that human error is normal. When leaders understand that error is normal, recognizing human error is not blame.
In my opinion, blame has a lot to do with perception. If an employee that made an error sees that the only system element that is being discussed is the Employee element, that will be perceived a certain way. It will be perceived as blame, and the learning will stop at that point unless something changes. If the information being provided is only being used against the employee, it is natural to expect that the information stream will stop, and then we will be stuck with incomplete information.
An employee that made an error, may even want to take full responsibility (and blame) for an event that went wrong. They may be disappointed that they fell into the human error trap and made a predictable and preventable error. Leaders, managers, and supervisors will be tempted to accept the apology and allow the employee to take more than their share of the blame. This is the easy way out. No organizational learning can occur if you let this happen, and there is a good chance that the error will occur again.
Instead, use this opportunity to learn about what happened, why it happened, and what else could have happened. There is a story about the work being done around this mistake that everyone needs to hear and understand before real solutions can be found. Provide support to the employees that could make that error again and find out what solutions can be implemented to make the human error less likely or less damaging. Focus on all four major work system elements of an organization and look for multiple solutions. Get input from employees that do that work and understand it. We should never lay blame when we are trying to learn, but we should also never allow someone in our organization to steal the blame in lieu of organizational learning.
Sincerely,
David Hanson, CSP
President, ASSP – Southern Oregon Chapter
Senior Safety Management Consultant, SAIF Corporation
Todd Conklin and Bob Edwards teach us that blame is the enemy of organizational learning. It is often pointed out that blame halts any learning that could occur. But how do we know when blame is occurring? Focusing on each of these elements may put decisions made by individuals under the microscope. When those decisions are identified as errors, is that blame? I would answer with a “no.” Conklin and Edwards tell us that human error is normal. When leaders understand that error is normal, recognizing human error is not blame.
In my opinion, blame has a lot to do with perception. If an employee that made an error sees that the only system element that is being discussed is the Employee element, that will be perceived a certain way. It will be perceived as blame, and the learning will stop at that point unless something changes. If the information being provided is only being used against the employee, it is natural to expect that the information stream will stop, and then we will be stuck with incomplete information.
An employee that made an error, may even want to take full responsibility (and blame) for an event that went wrong. They may be disappointed that they fell into the human error trap and made a predictable and preventable error. Leaders, managers, and supervisors will be tempted to accept the apology and allow the employee to take more than their share of the blame. This is the easy way out. No organizational learning can occur if you let this happen, and there is a good chance that the error will occur again.
Instead, use this opportunity to learn about what happened, why it happened, and what else could have happened. There is a story about the work being done around this mistake that everyone needs to hear and understand before real solutions can be found. Provide support to the employees that could make that error again and find out what solutions can be implemented to make the human error less likely or less damaging. Focus on all four major work system elements of an organization and look for multiple solutions. Get input from employees that do that work and understand it. We should never lay blame when we are trying to learn, but we should also never allow someone in our organization to steal the blame in lieu of organizational learning.
Sincerely,
David Hanson, CSP
President, ASSP – Southern Oregon Chapter
Senior Safety Management Consultant, SAIF Corporation
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