CRL 1-hr: 9/26 Introduction to Uptime Elements Reliability Framework and Asset Management System

Blame may not be a defined policy within an organization but subtle remarks, especially by managers, can be interpreted as endorsements of the blame game. Three common characteristics of this blame approach (to problem solving) in organizations are an unwillingness of employees to come forward with information about a problem, incomplete analyses of problems by concluding that “human error” was the cause and too much focus on “Who did it?” rather than identifying the causes of a problem by asking specific “Why?” questions.

Organizations that use the blame approach with employees apparently believe that they are making an example of an employee, discouraging others from making the same mistakes. In reality the lesson that everyone learns is, “If you see a problem or if you’re involved with a problem that’s keeping us from reaching our goals you better not tell us about it because if we find out you will be punished.” This approach is an effective way to further separate labor and management and dissuade anyone from coming forward with ideas. It creates a kind of organizational denial. Everything appears fine until suddenly a major incident occurs. Problems just don’t happen; they always have causes. Blame encourages employees to obscure the facts and redirect responsibility to avoid possible discipline.

Concluding an investigation with human error indicates an incomplete analysis. Human error only tells us that something wasn’t done effectively and people were involved. Human error is a generic category that provides no specific course of action to prevent the problem from occurring. Without the specific causes of the problem an organization may choose disciplinary action by default because that’s how it’s always been done. If we think a hammer has been effective in the past, everything may start looking like a nail. Effective problem analysis focuses on the specific causes of a problem.

Most problems or errors that occur within organizations are unintentional. This should be clearly communicated at the beginning of every analysis with all parties. Organizations sometime forget this and end up on a witch-hunt. People don’t usually start their workday by deciding how they’re going to screw up. When a problem does occur it’s typically due to something that we didn’t know or didn’t understand. A couple of important questions are “Why did it happen?” and “Why didn’t we identify it earlier?” Individuals and groups typically don’t ask enough “Why?” questions. Too many organizations only ask, “Who did it?” The thinking seems to be if we can find the people who are making all of these mistakes we’ll be able to solve the problem. The people that were involved with the problem are one of the best sources of information in a problem analysis. If they believe they’re going to get in trouble we’re not going to get accurate information. Without accurate information we cannot identify the specific causes that are required to find the best solutions.

This blame mentality may be reinforced by the organizations in which we work, but it typically starts much earlier. We learned early on that when we broke something in the room where we were playing mom or dad’s first question was “Who did this?” We learned that if it’s not me, unpleasant things aren’t going to happen to me. So as kids we respond with “he did it” or “she did it” or at least “I didn’t do it” and the finger pointing begins. This can easily develop into maintenance did it, marketing did it, operations did it, design did it, or purchasing did it.

Developing a prevention culture within an organization begins by having individuals take more responsibility. All parts of an organization need to work together effectively. Finger pointing is in the opposite direction. If a problem or error has occurred the responsible organization might ask, “How did we get someone in our organization, in that role, under those conditions that did not know the appropriate course of actions to meet our goals?” Finger pointing is symptomatic of an “immature” organization that is unwilling to take responsibility for its performance. Organizations need problem solvers not finger pointers. Every problem in an organization should be approached as an opportunity to improve. This approach doesn’t release the individual from responsibility; it actually demands increased accountability. Clearly defined roles, responsibilities and expectations must be set. It also gives ownership to the people involved with the problem to identify their own solutions.

Establishing a problem solving culture which focuses on prevention is a continuous effort. It must be part of regular (daily) communication within an organization. The prevention approach recognizes that everyone in an organization is part of the problem solving culture. Everyone has information about the problems they see daily and at least a few ideas of how to solve them. The benefits are better focus on the goals and less firefighting and recurring issues. Experiment with this prevention approach if better problem solvers with greater accountability are important to your organizational goals.

Mark Galley

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