Have you ever heard of the newest business term?

The Blameless Post-Mortem

Do you understand what it means to have a ‘blameless’ Post-Mortem?

This is touted as the New and Improved way of doing business. Take a very close, hard look.

Does it mean everyone gets off the hook for making mistakes? Not really.

Well, it actually depends on what “gets off the hook” means. This requires an explanation. Again, read this very carefully. This is the future of business and manufacturing and marketing and every other industry. It is “enlightened” leading edge.

And that edge might just be the side of a cliff…

It starts with Political Correctness, so watch the terminology because what it says is rarely what it means. A “Just Culture” is the basis. That means that you’re making effort to balance safety and accountability. It is a tight rope, and depending on perception of the moment, you are the hero or scapegoat. That is the simple explanation. The politically correct definition is as follows: It means that by investigating mistakes in a way that focuses on the situational aspects of a failure’s mechanism and the decision-making process of individuals proximate to the failure, an organization can come out safer than it would normally be if it had simply punished the actors involved as a remediation. Simple, right?

Having a “blameless” Post-Mortem process means that engineers whose actions have contributed to an accident can give a detailed account of:
• what actions they took at what time
• what effects they observed
• expectations they had
• assumptions they had made
• and their understanding of timeline of events as they occurred
…and that they can give this detailed account without fear of punishment or retribution. Which means they are free to do it again, perhaps in a different and more creative way next time.

Why shouldn’t they be punished or reprimanded? Because an engineer who thinks they’re going to be reprimanded are dis-incentivized to give the details necessary to get an understanding of the mechanism, pathology, and operation of the failure. This lack of understanding of how the accident occurred all but guarantees that it will repeat. If not with the original engineer, another one in the future.

Responsibility? Not relevant.

If the politically correct corporation were to go with the outdated concept of “blame” as the predominant approach, then we’re implicitly accepting that deterrence is how organizations become safer. This is founded in the ‘misguided’ belief that individuals, not situations, cause errors. It’s also aligned with the idea there has to be some fear that not doing one’s job correctly could lead to punishment. Fear of punishment will motivate people to not act correctly in the future. Again…Responsibility is not a factor here.

This Politically Correct/Just Culture cycle of name/blame/shame can be looked at like this:
1 Engineer takes action and contributes to a failure or incident.
2 Engineer is punished, shamed, blamed, or retrained.
3 Reduced trust between engineers on the ground (the “sharp end”) and management (the “blunt end”) looking for someone to scapegoat
4 Engineers become silent on details about actions/situations/observations, resulting in “Cover-Your-Ass” engineering (from fear of punishment)
5 Management becomes less aware and informed on how work is being performed day to day, and engineers become less educated on lurking or latent conditions for failure due to silence mentioned in #4, above
6 Errors more likely, latent conditions can’t be identified due to #5, above
7 Repeat from step 1

Do you see the key difference in traditional thought versus “modern” solutions? Political Correctness says we need to avoid this cycle. We want the engineer who has made an error give details about why (either explicitly or implicitly) he or she did what they did; why the action made sense to them at the time. This is paramount to understanding the pathology of the failure. The action made sense to the person at the time they took it, because if it hadn’t made sense to them at the time, they wouldn’t have taken the action in the first place.

The base fundamental here is:

We must strive to understand that accidents don’t happen because people gamble and lose.

Accidents happen because the person believes that:

…what is about to happen is not possible,

…or what is about to happen has no connection to what they are doing,

…or that the possibility of getting the intended outcome is well worth whatever risk there is.

The true advice here is that every new piece of advice about business needs to be scrutinized very closely before accepting is as better.

Seeking real direction and advice that can be trusted? Contact Blue Sand Group today!