This is a topic that provokes much debate and, as a consequence, deserves attention.
Around this topic we have comments worldwide such as:
“This is just a technical investigation“;
“We have a no blame policy in our company”;
“We do not acknowledge human failure only organisational failure“.
Before dealing with these issues, we must make two points clear:
1. Almost all failures can be traced back to human behaviour. Certainly, fuses blow, loads are dropped, engines run out of fuel, the wind blows, waves sink ships, and earthquakes kill people, but if we want to stop these events causing harm, then we have to intervene in one way or another. As soon as we take action, we are acknowledging that we got it wrong and could do better – we acknowledge human failure.
2. It must be emphasised that it is very dangerous to apply blanket rules in this debate. Some failures are minor and require very little attention, others cause no harm or damage, but are potentially hugely dangerous, and others actually do cause serious damage to People, Environment, Assets or Reputation (PEAR). But remember, the accumulation of a number of minor failures can result in major consequences.
So, how do we address this human failure? There are a number of issues here, and they are all worth considering.
Firstly, to acknowledge failure does not mean we have to use the word ‘blame’, and it does not mean that someone is in trouble or needs to be punished. That may be the case in a few situations, but it certainly isn’t the rule. It is perfectly possible to attribute fault without condemnation or criticism, and that’s a key issue for those making recommendations after an incident. It’s all about use of language, attitude, compassion, understanding and, fundamentally, care of individuals within the company.
Secondly, human failure does not have to be attributed to individuals. Root causes can be described in organisational terms, without naming names. So, it is perfectly reasonable to describe a root cause as ‘The company training policy has weaknesses’ without actually pointing the finger at a particular person. The SMART action in this case would be to review and strengthen the training procedures in a clearly defined and measurable way, and this can be done by the responsible person(s) without them feeling that they had failed in any particular way. So, the failure is clearly a human one, but it’s not being nailed to an individual.
Thirdly, at what level did the human failure take place? Often low-ranked workers make errors and are blamed for them. They may be taken off the job, reprimanded or even sacked. This may be appropriate, but to say that’s an end to it is dangerous. Managers who say, “It was Jim’s fault, and there’s nothing more can be done”, are simply leaving things as they are and waiting for the same incident to happen again. Good managers look at the failure and say to themselves, “Is there anything I can do to stop this happening again, with or without Jim?” Because Jim’s replacement, Svend, may be no more reliable. If Svend’s actions cause the same incident to happen again, and others are injured or equipment damaged, is the manager free of criticism? Certainly not. What’s the point of being a manager if you don’t look at all these failures and try to do something to reduce their recurrence? When you address issues within your remit, you are not at fault, you are just doing your job. However, if you fail to address these issues, then you are certainly at fault. Just because you are at the top of the tree, does not make you a perfect human being. Everyone is part of the system within which incidents can occur.