Whose fault is it anyway?

‘I’m fed up with this blame culture:’ said a client to me recently, ‘there has to be a better way of handling problems.’

This reminded me of the BBC Radio 4 programme ‘From the cockpit to the operating theatre’ which discussed the introduction of the aviation industry’s ‘no blame’ culture into the world of medicine.

This ‘no blame culture’ came about following investigations into airline disasters in the Seventies and Eighties which were deemed to be due to human error. In one case, an engine was on fire, the pilots believed it to the engine on the right and shut it down: however, simply by looking out of the window, the passengers and cabin crew could see it was the engine on the left. The plane crashed and forty-seven people died.

Investigation showed that four elements led to these errors:

  • Deference to authority (‘the pilots are in charge, they must be right so I’d better not say anything’)
  • Overloading of information
  • Distraction
  • Poor communication

Similar elements are present in surgery, leading to mistakes being made (eg operating on the wrong limb) with sometimes tragic consequences. The medical world is taking on the lessons of the aviation industry and has introduced procedures to mitigate the risks of human error.

Whilst neither my client, nor I, nor probably most of you reading this post, works in an industry where an error in judgement could have tragic consequences, it is possible that we work within a ‘blame culture’ and maybe we’d like to do what we can to change that.

No blame zone

My client listened to the Radio 4 programme and was struck by a conversation between pilot Matt Lindley and the interviewer, Claudia Hammond:

ML: We all make mistakes but what we need to do is try and learn from our mistakes, to mitigate the risk.

CH: So is it really true that in the airline industry people will admit their mistakes and even be congratulated for admitting their mistakes?

ML: The airline industry encourages us to admit even minor errors and the idea is there’s no blame associated, unless obviously there’s negligence … I make mistakes all the time and I report them all the time … and I don’t get a manager phoning me up, chastising me, asking me why things happened. Sure I might get a trainer phoning up and asking further smaller questions to understand why… It’s not a blame culture.

My client and I talked about how he could work with his team to see how those four identified elements (deference to authority, information overload, distraction and poor communication) affect them. He wants to change their team culture and see how that might ripple out and have an impact on the other teams with whom they work. His aim is to create an environment in which he and his team feel sufficiently secure that they can challenge and question. He hopes his team will be one in which they admit mistakes and don’t judge each other but rather learn from those errors.

Today’s pebble for you to consider:

Are you caught in a blame culture? Whilst you can’t change organisational culture overnight, what steps can you take to create a ‘no blame zone’ in your area?

What do you think?

Michelle

Turning over pebbles is the blog of Thinking Space Coaching. 

If you’d like to take action and create positive change in your work and life, why not email me to see how we could work together?

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4 Responses to Whose fault is it anyway?

  1. Hi Michelle – this is an interesting post and I came to your site doing some research following Matt Lindley being quoted in a BBC article on “speaking up” – http://www.bbc.co.uk/news/health-33544778.

    One of the most interesting things I saw on there was the encouragement to use trigger words, such as ‘I’m UNCOMFORTABLE. This isn’t SAFE” as it’s more personal and evocative that simply questioning authority in ‘normal’ ways.

    I’m editor of online HR publication HRZone.com and I just posted a response to this BBC article, written by David Buchanan, professor at Cranfield University, which takes a different tact to this issue and analyses it from a systems-based approach, based on extensive research that David has undertaken.

    I thought you’d be interested in this piece, which you can view here: http://www.hrzone.com/lead/culture/does-speaking-up-really-save-lives

  2. Matt Lindley says:

    Firstly thanks so much for taking the time to read the article, this was based on an interview I gave for BBC Radio 4 / World Service ‘From The Cockpit To The Operating Theatre’ http://www.bbc.co.uk/programmes/b05y16mv
    My answers are based partly on over 10 years involvement in Crew Resource Management / Human Factors in both industries, I not only teach the academic theory, but I experience it day to day as I am still a long haul pilot.
    Human fallibility is a reality, systems can be tweaked and adapted to help reduce this risk but the weak link is the human. When I am at the end of a 14 hour flight for example, the reality is that you are not as sharp and you do make more mistakes (look at the Asiana Crash at San Fran).
    Understanding these dangers, self awareness and culture change in how organisations deal with error are key.
    Healthcare suffers from human factors initiatives being parachuted in and not explained. The industry needs a comprehensive culture shift, a big part of this is education but also to get away from the blame culture. Healthcare professionals fear Management, litigation and career limiting investigations.

    • Matt, I really appreciate you a) reading my post and b) commenting on it. Since I first heard the radio 4 piece, I’ve read a little more about your work and it’s fascinating. Thank you again.

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