SafetyInsights.org

Using discourse analysis of transcripts from 34 simulated incident interviews, this study explored the role of a “no blame ideology” on the investigation process.

Providing background, they note:

• “Conklin’s (2019a) neat mantra that ‘blame fixes nothing’ is so prominent in safety discussions across North America that it is arguably now simply part of the vernacular” (p1)
• Prior UK work found that construction workers “fully expect blame and punishment” as part of site safety, seeing it as a “necessary counter to their need (and in some cases choice) to bend and flex site rules in order to get the job done” (p1)
• Other work has argued that a unidimensional focus on creating a no-blame environment carries its own safety risks, moreover others have argued that “systemic safety’s absolution of individual performance and accountability meant workers were effectively ‘written out’ of the safety story, which in turn made it impossible to hold them accountable for poor behavior” (p3)
• Moreover, the language used in investigations can be relevant, as it can shape and influence all parts of the process – even the order that information is presented can influence judgements of culpability
• Some firms are noted to have shifted to incident evaluations rather than incident investigations, to avoid punitive language associated with criminal investigations
• Blame has a ‘dubious history’ in construction safety, such “to the extent that blame has even been weaponized against workers” (p4)
• Elsewhere, the investigation process has been argued to be used as a proxy for performance management and directly linked to a HR disciplinary process

Note: For just an 11-page paper, it is packed to the brim with findings, so I can only provide a few key points.

Results

Some key findings were that:

• A kind of bias was found during the analytical work—not the psychological bias—but rather a “dogmatic adherence to no blame within the investigative process” (p4)
• This dogmatic adherence bias was called ‘New blame’, and was noted to have detrimentally influenced and shaped investigation interviews
• New blame “renders interviewers reluctant to unpack the people in the process, and instead directs focus on things easily blamed without consequence, such as inanimate objects, organizational procedures, or paperwork” (p1)
• They argue that without understanding how workers interact with their work or what went wrong this time, learning is inevitably limited
• At the most extreme level, new blame may take safety back to ‘Acts of God’

New blame was ‘readily recognizable’ as a preamble comment/s from the investigator to the worker before the interview questioning commenced. For instance, investigators would start with comments like “we’re not looking to fix people. We’re looking to fix our processes and systems so that you guys on the front line will be set up for success”.

In some cases, these preambles were said to be presented in a rehearsed manner and with “the language of HOP clearly evident” (p6).

Interviewers drew clear distinctions between people and processes, emphasising the need to focus on improving processes that support people when people inevitably make mistakes.

The researchers note that despite the investigator providing reassurance to the workers, blame was still present. In fact, investigators in trying to avoid blame brought blame into the conversation within the very first sentence. As they argue, using this type of blame-avoidance language in the preamble “has the practical effect of actually placing blame at the very top of the agenda – it becomes the first thing mentioned, elevating its importance within the situation for both interviewer and interviewee environment for the rest of the interview” (p7).

Blame was positioned in the negative frame and associated with punishment, despite being different activities.

They argue that via new blame, blame is centrally positioned throughout the interaction from the very start of discussions. However, such early promises of ‘no blame’ before the investigation has been undertaken shouldn’t be made, since it is unknown at this point what appropriate actions will be (which may involve direct and personal culpability).

Further, “early assurances of no blame become both presumptive and pointless” (p7) and in cases where disciplinary actions etc. are appropriate, these early assurances “then becomes just another management lie; a tool for enhanced data extraction, grounded in reassurances that simply melt away” (p7) and introduce promises that may have to be broken; damaging trust.

New blame was found to direct attention to things that could be blamed without immediate consequences for the interviewee – including poor materials, inanimate objects or lack of training, while also avoiding questions around the actions or behaviours of workers directly involved in the event.

Here, investigators frequently shortchanged the collection of information around behaviours etc., thereby not properly exploring the context of workers and how they fit into the incident.

New blame directed attention to inanimate objects – e.g. many investigators focused on the specification and construction of a staircase that was involved in a collapse. While this was a logical direction to explore, “it also provided a relatively comfortable space for enquiry” (p8). That is, the staircase is “utterly unresponsive” to criticisms or blame, as opposed to individuals, so makes for a comfortable target of the investigation.

Moreover, potential cues relevant to the investigation surrounding individual behaviour (like prior firings of staff) were rather glossed over in preference to factors of the objects or system factors like production pressure. New blame also directed attention towards the role of procedures and paperwork.

As the authors state, the focus on objects and systems provides the “blameable, faceless ‘organization” (p9).

Not all investigators avoided the role of people in the process – some were more direct around agency. However even in these cases, new blame “still held influence even within such interviews, supporting and directing conclusions to be drawn that again ultimately championed no blame as the final outcome” (p9).

Avoiding the role of people is said to limit learning, since organisations are made up of individuals. New blame oversimplifies the situation and “prompts a predetermined conclusion of ‘organizational issues” (p9). They argue that if responsibility cannot ever be attributed to individuals then we will struggle to fully understand the actions of people and why what they did made sense [** although I’ve never seen this hypothetical ‘no blame’ organisation and even in the most progressive ‘just’ and restorative environments, individual accountability and responsibility always existed.]

Finally, new blame at an extreme level may have reintroduced the concept of ‘Acts of God’, largely intangible or uncontrollable forces that are readily blameable. They argue that “Whilst culture or production pressures may indeed be causal factors within an incident, without understanding of how people are affected by them, how the workers fit into work as structured by these constructs, they are as practically useless as once again ascribing responsibility to an ethereal deity in the sky” (p10).

Authors: Sherratt, F., Thallapureddy, S., Bhandari, S., Hansen, H., Harch, D., & Hallowell, M. R. (2023). Safety Science, 166, 106247.

Shout me a coffee

Study link: https://doi.org/10.1016/j.ssci.2023.106247

Link to the LinkedIn post: https://www.linkedin.com/pulse/unintended-consequences-blame-ideology-incident-us-ben-hutchinson