“If everyone is moving forward together, then success takes care of itself.” Henry Ford
Your company has had an incident or a near miss, the investigation is closed and the cause has been determined. Now what? In an ideal world, the goal is a return to normal operations with a lower likelihood that the incident occurs again. So, how do you achieve this goal? A common approach is to focus energy on what figuring out who made a mistake because of the belief that if something bad happened, someone had to have made a mistake. Alternatively, you can concentrate on acknowledging the harm, and focus on making changes to what should be done in the future. Accountability is key, but you need to know where to look for it.
Accountability breeds response-ability
Accountability can be loosely defined as the obligation of an individual or organization to account for its activities and accept responsibility for them. It’s a word that is often associated with negative connotations like blame or fault. However, accountability does not always mean that someone is at fault. Sometimes it’s acknowledgment that harm was done and things need to be different in the future. Prevention of all incidents is ideal, but the only way to achieve such a lofty goal is to identify and address all hazards, and to do so would require zero budgetary limitations. Obviously, this isn’t a feasible solution, so we look to accountability instead to better prepare ourselves and lower the likelihood of a recurrence. But in what direction should we look?
The negativity related to accountability stems from its correlation to words like blame and fault. This desire to assign blame is backward-looking, and associated with hindsight bias. The problem with hindsight is that in hindsight, every incident seems preventable and causes and potential preventions are obvious. This isn’t the case—not all incidents are foreseeable or preventable. Hindsight also tends to oversimplify. It leads us to assume that if the outcome is good, then the decisions and the systems are good, or that if the outcome is bad, then the decisions and the systems are bad. However, a decision can’t be a good decision on some days and a bad decision on others. If a process is bad or a behavior is negligent, the process is bad and the behavior is negligent whether harm results or not. This lack of gray area is problematic as it overestimates the likelihood of the outcome, overstates the role of rule or procedure violations, and matches outcomes with the actions that went before them. However, we know the world isn’t so black and white.
Every Friday afternoon, every week, I stop at the gas station near my home to fill up my car and then head inside to buy a five-dollar scratch off lottery ticket. I take it home, cross my fingers, and scratch it off. Sometimes I win, sometimes I lose. Regardless, every week I follow the same process and sometimes the same process that leads up to a bad outcome can lead up to a good one. (By the way, I know that buying a lottery ticket is not a good process if optimizing profit is the objective; I do it because it’s fun.)
The same is true of processes in a plant. A process that leads to unacceptable outcomes is a bad process, whether or not it always leads to unacceptable outcomes. If we are only looking back at performance after an incident, we are enabling the oversimplification that good decisions and systems breed good outcomes, and bad decisions and systems breed bad outcomes. Again, as we look behind us for answers, we point fingers and declare fault even when doing so does not lead to a reduced likelihood of a reoccurring incident.
The very nature of prevention requires us to understand hazards. We must first know what can go wrong, or in the case of an incident what went wrong, to know how to address future prevention. Hindsight analysis does not reveal how many possible causes underlie the total set of accidents, nor does it reveal how costly the elimination of all these causes would be. So when an incident happens, instead we should acknowledge the harm from the mistakes, and assign responsibility for making changes to reduce the probability of harm in the future. This sort of accountability is forward-looking. You can’t prevent an incident without first discovering what can or did cause it, but the key is acknowledgement and moving forward before blame and repercussions for what has already been done.
Keep your head up
Growing up, my mom frequently told me to, “Look up and watch where you are going or you are going to fall.” This is a lesson I’ve done my best to carry through life. When you are always looking backwards, you stumble over new obstacles and must pick yourself up time and time again, only to continue the same repetitive motion. When you learn to look ahead, those obstacles are obvious and avoidable. You can’t move into the future looking backwards; you’ll trip, stumble, and probably fall, but if you keep your head up, the path gets a lot less daunting.