“This is an unfair thing about war: victory is claimed by all, failure to one alone” according to Tacitus, Agricola 27:1 (98 AD) (2007). In today’s world there are various systems of limited accountability. It is not clear that any of them truly address the risks of cognitive biases.
When admitting responsibility, one can take the actions to prevent repeating an accident. The problem is that responsibility is associated with accountability. Therefore, nobody wants to admit responsibility. The common practice is to look for somebody else’s accountability. The result is that the persons who can prevent the next accident are busy blaming people, typically the operators, instead of learning from the accident.
More than 2000 years ago, the Roman philosopher Cicero (Wiki ...) already observed that "to err is human". The 18th century English writer Alexander Pope ( Wiki ...) added that "to forgive, divine", suggesting that the term " error" is associated with blame.
Typically, an incidence may be attributed to several sources. In a typical investigation procedure, managers are enquired about the means applied to avoid the recent mishaps, and about their plans to prevent similar mishaps in the future. Often, the managers cannot provide adequate explanations and plans: they cannot control extreme situations, such as faults, they do not have deep knowledge about technological issues required to demand significant changes in the engineering procedures and staffing. They cannot convince the stakeholders to invest design changes that are not well understood.
If the managers initiate procedure of learning from the incidence, they actually admit their responsibility. Therefore, managers often look for ways to work around the topic. The only available way to distract the investigation to a different channel is by blaming the operators. Typically, this option is easy to handle, because the operators cannot remember exactly the sequence of activity and situation changes prior to the incidence, they cannot justify their actions, and they cannot repeat it to help with the investigation. Blaming the operators enables the management to show that they actually do something about it.
Updated on 05 May 2017.