SH181: “Blame is the enemy of safety” - moving from blaming to learning

Mistakes, slips, and lapses are a natural part of human performance, influenced by factors like training, time pressures, and equipment design. While rule-breaking may seem deliberate, it's often shaped by context, social pressures, and the perceived benefits of deviation. Biases like hindsight, outcome, and severity distort how we interpret incidents, leading to blame rather than understanding. Effective learning requires exploring why decisions made sense at the time and avoiding counterfactual judgments like "should have" or "could have." By shifting from blame to understanding and investigating systemic factors, we can improve safety and performance in diving and beyond.

Original blog: https://www.thehumandiver.com/blog/from_blaming_to_learning

 

Links: Research about anaesthetists: https://pubmed.ncbi.nlm.nih.gov/18941971/

Bad apples: https://gue.com/blog/do-bad-apples-actually-exist/

Attribution of agency: https://gue.com/blog/the-role-of-agency-when-discussing-diving-incidents-an-adverse-event-occurs-an-instructor-makes-a-mistake/

Further reading: To blame is human. To fix is to engineer. https://www.academia.edu/527985/People_or_Systems_To_blame_is_human_The_fix_is_to_engineer 

The Field Guide to Understanding Human Error. S. Dekker.  

Chartered Institute of Ergonomics and Human Factors: Learning from Adverse Events https://ergonomics.org.uk/resource/learning-from-adverse-events.html 

US Forest Service - Learning Review Guide. https://www.fs.usda.gov/rmrs/coordinated-response-protocol-learning-review 

"Blame is the Enemy of Safety" from Engineering a Safer World by Nancy Leveson.

Tags:  English, Gareth Lock, Incident Analysis, Incident Investigation, Incident Reporting, Just Culture