4 thoughts on “Blamestorm

  1. How strange you should post this. I have been thinking of how organisations adapt. It does seem many have adapted to avoid/shift blame rather than succeed at what one might think are more fundamental criteria for success.

    This seems to be partly a confusion between what I might call internal and external adaption. Deciding responsibility and blame may be appropriate within a unit (a very human method but not necessarily effective) but not externally, where general success should be more important and blame does not work so well (gross generalisations here!)

    This is partly a social dilemma. avoiding blame may be to the advantage of an individual but not to the organisation they are part of.

    I dont have any quick answers to this problem, however a couple of examples from Air Safety are interesting. There is a rule that pilots can not be disciplined for a near-miss, even if they were negligent. This means that near-misses get reported, investigated and maybe the causes identified and fixed. The second is from WWII. Too many US bombers were crashing for reasons other than being shot down. They tried various sorts of quality control and checks, but these did not have any effect. What did work was making the engineers fly on about 1 in 100 flights at random.

  2. You provide two fascinating examples of how to learn from human error. Blaming is not a solution while learning from our mistakes at least leads us towards a solution. Going along with your air safety theme, I remember reading about how an auto pilot device works. The plane flies on auto pilot until it is off-course it then adjusts itself until it flies off-course once again (and so on). This means the flight ends up as a zig- zag across the skies rather than a straight line. It is an intriguing progression where the target can only be reached via repeated errors.

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