Ban the Blame

| December 15, 2009

One of the key requirements of the OHSAS 18001 standard is establishing a procedure for taking corrective and preventive action (section  Both corrective and preventive action need to include identifying the underlying causes – often called root causes – of whatever it is that is or went wrong. 

This is not easy.  Often, the root cause investigation ends with a determination along the lines of “Joe screwed up.”  We play the blame game.


There have been a number of reasons advanced for this and most of them are probably true – at least in part.

Last week, a colleague lent me his copy of Dan Gano’s book – Apollo Root Cause Analysis: A New Way of Thinking

This book sets out a different way of approaching root cause analysis by focusing on defining a problem in terms of both the action and the conditions that caused the particular effect you are analyzing.  For example, you don’t get a fire (an effect) unless you have an ignition source (an action) as well as two conditions (fuel and oxygen at the right concentrations).  Remove either condition (fuel/oxygen) or the action (ignition) and the effect (fire) does not occur.

What I liked most about the book, however, was not the root cause methodology advanced in the book but the explanation of why we so often fall into the blame game.

In a word – storytelling.

As humans, we have a long tradition of storytelling.  It comes naturally to us.  It is how we have transmitted information for generations.  Everyone likes a good story.

Integral to storytelling is identifying your actors – answering the question “who” is central to telling a good story.  As Gano points out in his book, most incident reports provide a prime example of storytelling.  The initial focus is typically on who did what.  Unfortunately, for purposes of root cause analysis, storytelling sets us up for failure because it keeps us focused on the story – who, what, where and when – rather than focusing our attention on identifying the causes of an incident. 

So when you are investigating an incident or nonconformity, tell your story.  It is, after all, human nature and likely irresistible.  But when you start your root cause analysis, put the story aside and take the “who” completely out of the analysis.  Remove the names and strike the identifiers.  Instead, focus your attention on the actions and conditions that lead to the situation (effect) that you are investigating.

© ENLAR® Compliance Services, Inc. (2009)

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Category: OHSMS Implementation, Resources & Tools

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