To blame or not blame – that is the question
There has been a rash of social media articles and postings lately by consultants and other safety folks making the seemingly absolute claim that organizations today are defaulting to blame when there is a workplace accident.
The trend I’m seeing is that those social media assertions are made as if investigation conclusions of blame were an absolute fact. They assume blame is automatically assigned after an incident, and they spin their no blame mantra using blame as a straw man. But I personally don't believe the perception of blame after incidents is as pervasive or widespread as some of these consultants and safety folks assert. I believe they are using this straw man argument to help spin their approach and market themselves and their services.
So, where's the objective evidence of this pervasive blame assumption? It doesn’t exist. Just as the objective evidence of my opinion to the contrary doesn’t exist.
Blame assertion vs actual blame
That said, let me explain, as there is an important evidentiary distinction here.
The existence of blame as a possible response to workplace incidents is well documented. But the much stronger proposition that blame is routinely or automatically assigned after workplace incidents is a different empirical claim, and I personally don't see evidence sufficient to treat that proposition as an established fact.
What evidence actually supports
There is in fact considerable research showing that fear of blame or punishment can inhibit reporting, particularly in the healthcare sector. For example, Cooper et al. examined blame in patient-safety incident reports specifically because the extent of blame attribution was unknown. That wording is significant: the researchers were investigating the phenomenon rather than starting with evidence that blame was universally occurring.
Is just culture the answer?
Likewise, research and professional literature on concepts like "just culture" commonly identify fear of punitive responses as a potential barrier to reporting. But that establishes a recognized risk or organizational phenomenon, not its prevalence across workplaces. AHRQ's description of just culture, for example, explicitly combines systemic analysis with individual accountability, including accountability for reckless behaviour.
A culture of blame – what does it look like?
And there is an interesting admission in the literature: Waring's influential work on medical incident reporting described "culture of blame" as a recognized barrier but noted that there were few detailed qualitative accounts of medical culture concerning incident reporting.
Enter the straw man argument
Now here’s where the straw-man argument becomes interesting. There are actually three separate propositions on the workplace incident/blaming scenario that frequently get collapsed into a single assertion:
- Organizations sometimes blame individuals after incidents. This can be considered obviously true, even within the context of my own personal experience in incident investigation over the last 40 years.
- Some organizations have a tendency towards what some call a blame-oriented culture. There is in fact evidence for this, particularly in healthcare and some other high-risk environments.
- Incident investigation normally begins with an assumption of individual blame, or workplaces generally operate this way.
It’s the third point that needs critical examination, as that assertion requires considerably stronger evidence. The third proposition doesn't automatically follow from the first two. And there's another important distinction - finding a person's causal contribution is not the same thing as blaming that person. Yes. . . an individual’s action(s) can indeed be the cause of an incident. Good investigations will also identify other influencing factors, but an individual can indeed cause an accident. That is a fact even by the simplest definition of ‘cause’.
Punishment or learning opportunity?
An investigation can conclude that Wayne's decision caused the event without concluding that Wayne should be punished/disciplined in the punitive sense, that Wayne is morally culpable, or that Wayne is responsible for preventing every contributing circumstance.
That distinction, in my opinion, gets blurred remarkably often. The "no blame" argument can therefore become circular. The rhetorical structure can look something like this:
- Premise: "Traditional safety investigations blame workers."
- Solution: "We need a no-blame approach."
- Evidence that the traditional approach is defective: "The fact that we need a no-blame approach."
That circular logic can be appealing unless the original premise has independently demonstrated evidence behind it.
Interestingly, even the literature which advocates the concept and principles of a “just culture” increasingly recognizes that "no blame" isn't actually the appropriate objective. AHRQ describes just culture as maintaining individual accountability while addressing system issues. Much literature therefore distinguishes between unfair blame/punishment and legitimate accountability. And the phrases culpable and non-culpable behavior carry tremendous weight here.
And let’s not forget that as a basic premise, safety folks don’t (shouldn’t) have the responsibility for any type of workplace discipline or “blame”. If anything, their role should be professional, competent and fact-based investigation efforts. Capture the evidence, plain and simple, and form conclusions based on that. If safety folks are the ones blaming those involved in incidents we have a completely different issuel
A 2023 paper by Sherratt specifically examined the "unintended consequences of no blame ideology" in incident investigation, which is another indication that "no blame" itself is not an uncontested evidence-based conclusion. In fact, the research noted, “. . . during the research, a phenomenon emerged that did indicate a type of ‘bias’ associated with blame (or specifically no blame), which directed and shaped investigative questioning in a variety of ways with the potential to inhibit the investigation process as a whole”.
Challenging the Assumption
The discussion around blame will continue and opinions on their utility will continue to vary. There are numerous perspectives on whether blame is good or bad, but it might be just as prudent to ask:
"What empirical evidence demonstrates that workplace incident investigations, and those with investigation responsibilities, generally begin with, or routinely result in, the assignment of blame?"
It might then be just as reasonable to answer that question with another question:
"What proportion of workplace investigations actually result in an individual being blamed or disciplined?"
But perhaps the most important question to ask of the safety consulting blame police is, "Are you demonstrating the prevalence of blame, or merely demonstrating that blame can occur?"
Those are very, very different propositions.
If a consultant cannot answer those questions with actual data, then "the safety industry is dominated by blame" is nothing more than an assertion, philosophy, or rhetorical premise - not an established empirical fact.
Culpable vs. non-culpable – a critical investigation hinge
The criminalization trend to serious workplace safety incident over the last 25 years has exposed a lack of global uniformity of how and where the line between where honest professional mistakes and criminalization is to be drawn.
And culpable vs. non-culpable behavior, as noted, is a critical key in the argument. So, keep this in the back of your mind whenever any incident you’re investigating eventually raises the question of blame, and whether blame will address the facts surrounding the cause and other influencing factors of the incident. And if not already a part of your investigation protocol, procedure or definitions, consider adding them for clarity, and educating your management team. They can make a big difference for those who’ve been handed the authority to meet out or withhold blame, for what it’s worth.
Culpable behaviour: Behaviour is culpable when a person knowingly or negligently violates a reasonably established safety requirement, duty, instruction, or expected standard of conduct, where the person has the knowledge, ability, opportunity, and reasonable control necessary to comply. In practical terms, the investigator is asking: “Did the person have a reasonable obligation to act differently, understand that obligation, and have a reasonable opportunity and ability to do so?”
Non-culpable behaviour: Behaviour is non-culpable when the evidence does not establish that the person knowingly or negligently breached a reasonable safety requirement or duty, or when the person lacked the knowledge, ability, opportunity, or reasonable control necessary to comply. Or simply made an error. This includes situations where a person's action or decision contributed to the incident but there is insufficient evidence to attribute fault or blame to that person.
