A No-blame Culture Misunderstood 

Two true stories: 

1. A doctor administered the wrong drug in error and a patient died.
2. A helicopter pilot put the wrong fuel in the fuel tank and the engine stopped mid-air. (Fortunately, the helicopter was landed safely, and no one died.) 

The doctor was administering an anaesthetic drug and had two syringes on her tray, both filled with different drugs. She picked up the wrong one, injected the patient, and moments later realised her error. An emergency was declared, and everything was done to reverse the effect of the drug, but the patient died. 

The helicopter pilot was shown a glass of the fuel to be put in the tank so that he could smell it and see its colour. However, after confirming it was the correct fuel, somehow the wrong fuel was added to the tank. 

What is interesting, though perhaps not surprising, is that, in both cases, the individuals involved took and expected full ‘blame’ for the errors; it did not occur to either of them that it lay anywhere else. 

What is a No-blame Culture?

A modern synthesis of these two incidents is that both individuals at the sharp end should not bear the entire burden of blame; the incident was caused by other factors. This is the product of a ‘No-blame Culture, an approach that seeks to avoid assigning any blame or fault to individuals when incidents or errors occur. Instead, the focus is on identifying and addressing only the systemic issues and contributing factors that led to the incident rather than singling out and punishing individuals.

What are the implications for organisations and incident investigation? 

Adopting such a culture can have some positive effects. It can increase and encourage open and honest reporting of incidents and near-misses because individuals feel less fear of retribution or punishment. This transparency can lead to a better understanding of systemic causes, enabling more effective preventive measures. Additionally, it can foster a learning environment where individuals feel comfortable sharing their experiences and contributing to process improvements. 

Incident investigations within a No-blame Culture typically involve using a systematic approach that focuses on identifying the contributing factors whilst avoiding assigning any individual blame, which is not the point of the exercise. This includes examining organisational processes, procedures, training, equipment design, and other systemic elements that may have played a role in the incident. The goal is to learn from the event and implement corrective actions to prevent future occurrences, rather than solely placing blame on the individuals involved. 

However, the pendulum can swing too far where incidents such as those above are put forward as good arguments for having a No-blame Culture, simply to avoid individual culpability. Though well-intentioned, this can create a sense of complacency or lack of personal accountability if taken to an extreme. There is a risk that individuals may feel absolved of responsibility for their actions, which could undermine safety and quality standards. It is also unhelpful for understanding the real causes of incidents and therefore preventing them.  

The two individuals here are not without fault, but the fact they were able to make these errors also lies with deeper, more complex aspects of the incidents. Equal blame, or perhaps more, lays with those who designed the procedures, who didn’t accurately assess the risks and put barriers or defences in place to prevent such events, thus creating the conditions that made it so easy for these errors to occur. 

How is a Just Culture different and what does this mean?

A Just Culture is one that balances this accountability and learning. It recognises that individuals should be held responsible for their actions where appropriate, particularly in cases of reckless or intentional violations of rules and procedures. However, it also acknowledges that human error is inevitable and that systemic factors contribute to incidents. In a Just Culture, individuals are not punished for mistakes or unintentional errors, but rather, the focus is on learning from these events and improving the overall system to reduce the likelihood of similar occurrences. Incidents don’t happen in isolation.

Organisations must strike a balance between creating an environment where individuals feel comfortable reporting incidents and near-misses, while still maintaining appropriate levels of individual responsibility. A Just Culture aims to achieve this balance by fostering an atmosphere of trust, open communication, and continuous improvement, while holding individuals accountable for intentional or reckless violations that compromise safety or quality.

Effective incident investigation ensures all avenues of enquiry are followed and that ‘no stone is left unturned’. Human error contributes to incidents, but that is not to say there is one person to blame – organisations are made up of interconnecting systems. By focusing objectively on all the failures that allow an incident to occur, organisations can help create a more open culture, encouraged by the understanding that robust investigation uncovers real root causes, and indeed all causes of an incident, but is neither seeking to find fault or to avoid blame.

A just culture is a one based on positive learning and proactivity, which ultimately leads to more effective investigations and business improvement.

To find out how Kelvin TOP-SET can improve the quality, consistency and efficiency of your incident investigations, get in touch via the contact form below.