The Blame Cycle
Occupational Safety researcher James Reason describes a destructive cycle that organizations and people can find themselves trapped in: The Blame Cycle.
The irony of the Blame Cycle is that, in an effort to foster accountability and minimize risk to the organization, the organization goes about it in a way that leaves itself more exposed to risk as a result. But it’s even more confusing than that - we can convince ourselves that we’ve done something good, that we’ve taken a strong stance, that we’ve learned our lesson and are turning the ship around.
How does the Blame Cycle show up in outdoor / experiential education programs?
At Experiential Consulting, we have worked with a wide range of outdoor programs, from outdoor education to camps, schools, therapy, and conservation corps. The Blame Cycle can be found in practical, hypothetical examples from all of them.
Blame drives reporting underground: A wilderness therapy field guide is driving a van to a trailhead and slides off the steep, muddy BLM road. The first thing the office does, upon hearing of this report, is require the field guide to be tested for drugs or alcohol use. Sometime later, they begin noticing dings, dents, or other new damage to vehicles that were never reported to them.
Blame and shame suppresses learning: A summer camp reports incident data at the end of each summer season to the leadership and board of directors, and has to submit that data and trends to maintain accreditation status each year. A first year counselor submits a “near-miss” report after almost tipping over in a canoe and is asked to stand up in a staff meeting to talk about the mistakes they made and what policies weren’t followed. They never submit another near-miss report again.
Zero Tolerance Policy Backfires: A conservation corps leader tells an inappropriate joke using explicit language around the corps members and offends several of them. This is brought up by the program director to the HR department, who terminates the leader immediately and issues an organization-wide memo that there is “zero-tolerance for any kind of sexual misconduct or harassment.” As a result, leaders and corps members are reluctant to report future occurrences, for fear of retaliation against the offender in question. The HR department believes that the memo worked as intended, as the number of reported incidents remains low.
Pursuit of Zero Incidents Backfires: An outdoor education program has a sign prominently displayed in their equipment warehouse: 237 days since our last on-the-job injury. A logistics coordinator is working in the warehouse all alone, and stacks a few plastic storage bins on top of each other and climbs on top to change a light bulb that has burned out. The boxes give way under his weight and he badly sprains his wrist as he falls to the ground. No one sees the incident happen, and he’s afraid he’ll get in trouble if he reports it. The next day, the sign reads “238 days since our last on-the-job injury.” Who wants to be the one who speaks up and makes the sign reset to zero?
The easiest thing in the world to do, with the lens (or burden) of hindsight after an incident has occurred, is to find and blame human error. In fact, the worse the outcome, the greater the tendency can be to search for an equally sizable cause (a phenomenon called symmetry bias). It’s tempting to settle for that simple story - and it’s convenient (even comforting) for us to be able to say that we have analyzed and identified the problem, and corrected it. But the binary, mechanistic world view in which an incident is caused either by an equipment malfunction or user error is, itself, a construct, a way we simplify the complex world in which we live and work. When we settle for the simple story of blaming human error, we rob ourselves of the opportunity to look deeper within the organization, to understand how close we may have come to that incident happening before, and taking the steps needed to change the workplace conditions that made the incident possible or likely to begin with.
As Dr. Todd Conklin says, “when we look for human error, we will find it 100% of the time.” But that’s like blaming a climbing fall on gravity. It’s certainly part of the story, and maybe the fall wouldn’t have happened without it, but it’s not “the cause” of the fall. In the words of Dr. Sidney Dekker, when we "declare a war on human error," we may end up making our organizations and programs less safe. A better approach is to treat incidents and near-misses as learning opportunities, and to seek to understand how the actions people took made sense to them at the time.
Additional reading and learning:
Dekker, Sidney. The Field Guide to Human Error, 3rd Edition (2014)
Lloyd, CLive. Next Generation Safety Leadership (2021)
Reason, James. Human Error (1991)
To learn more, join us at the 2024 Wilderness Risk Management Conference to hear Steve Smith present a core workshop on "Beyond Theory to Practice: Practical Applications of Safety II."
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