Notes on Failure and Blame

Identifying the causes of failure may be an essential condition for organizational learning. Refusal to blame may lead to a refusal to understand, or even a denial that failure has occurred / is occurring. 

However, where problems are systemic or due to process design, blaming individuals obscures the problem. A blame culture also leads to an avoidance of risk. 

 

Component as scapegoat - a part takes the blame for the whole

I have lost count of the number of analyses I have read about NASA and the failure of the space shuttle. Blame the O-ring. Blame the management. Blame the narcissism of the organization [Schwartz]. 

What was most striking about these investigations, especially in the early days as the press speculated on the findings, was the tendency to focus on what, in particular, had caused the problem. It had the flavour of trying to find an appropriate scapegoat, so that certain parts of the system could be free from blame. [Smith and Berg, p 156] 

Individual as scapegoat - a person takes the blame for the system

In both health and transport, there is a tendency to blame individuals for faults in the system. Individuals are characterized as Bad Apples, as if this acted as a satisfactory explanation or excuse. 

A recent British TV programme showed a number of cases of health workers whose careers were ruined by a single error. A nurse who picked up the wrong injection after a 30 year unblemished career, and killed the patient. A pharmacist who failed to distinguish between two almost identical packs. (Obviously higher status professionals don't get scapegoated so easily.) 

By blaming the individual, the system remains unaffected. Blame is therefore a mechanism for preserving the system.

 

With transport (e.g. rail crashes) we have two opposite tendencies. One is to automatically blame the driver or the pilot. The other is to postulate some outrageously expensive piece of technology, such as a state-of-the-art signalling and braking system, and claim that this technology would have magically eliminated all risk. The fault then lies with The Management for being too mean to invest in this life-saving technology. 

Grief (for example the bereaved relatives) can then be converted into anger. With rail crashes, the driver's often among the dead, so it's apparently better for the relatives (and the media) to have a living target for this anger (and revenge). Another mechanism which sustains a blaming culture.

And then there's the lawyers. 

 

Examples

Schrecklichkeit (August 2004), A Bit of a Dump (April 2008), Emotional Intelligence (September 2010), The Quantum Organization (November 2015), Jaywalking (November 2019)

 

References

H.S. Schwartz, Narcissistic Process and Corporate Decay: The Theory of the Organizational Ideal (New York: New York University Press, 1990)

K.K. Smith and D. N. Berg, Paradoxes of Group Life (San Francisco: Jossey Bass, 1987)

 

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Originally published at http://www.veryard.com/tcm/failure.htm 26 July 2004