The blame cycle

Another graphic from James Reason. In his vulnerable system syndrome paper (link below) he talks about types of “pathologies” present in many organisation; which predispose them to adverse events.

Three interacting and self-perpetuating elements are involved: blaming front-line individuals, denying the existence of systemic issues and a blinkered pursuit productive and financial indicators.

Three core pathologies in particular drive a cycle of blame. These are:

1.. The fundamental attribution error: where we explain a person’s behaviour as more products of their own agency and personality traits rather than also as products of the environment. Jim says this is “one of the main reasons why people are so ready to accept the phrase “human error” as an explanation rather than as something that needs explaining” (p22)

2.. Illusion of free will: a belief, particularly in Western cultures, that people are controllers of their own destiny. Because we feel capable of natural choice leads us to assume others are the same. Free agents, free to choose between right and wrong, per process or against process (as if there’s no middle-ground) – and without due influence of organisational factors & pressures.

He notes research showing that when people are asked to judge which causal factors were most avoidable, they invariably select the human actions.

3.. Hindsight bias: Where we see past events as “somehow more foreseeable than they actually were” (p22). When we know the outcomes of an event, our perceptions of how and why it occurred have been unconsciously coloured.

He notes “Those blessed with outcome knowledge see all the lines of causality homing in on some clearly defined happening, but those equipped only with foresight do not see this convergence” (p22).