A Blame-Apportioning Culture - the Effects

Accidents are symptoms of problems within an organisation. By addressing only these symptoms, a company may find itself with an accident rate intolerable to all. Accident prevention methodologies focussed only on the symptoms are doomed. Proper accident investigation is the primary tool to establish the information required to effectively reduce accidents on a fundamental level. According to the American Society of Safety Engineers (1999) a punishment-orientated culture ignores this information and is counterproductive to effective accident investigations.

Rather than punishing, management should try to determine what motivates employees to act unsafely, or why workers do not understand what they are supposed to do. Managers often settle for punishment because it is easier than searching for fundamental contributing factors.

The focus on the so-called immediate or proximate causes, often called unsafe acts and unsafe conditions (not wearing proper personal protective equipment, using the wrong tool, ignoring established procedure), are on tangible elements and it is obvious why the uninformed will tend to focus an investigation on these factors. In the absence of in-depth accident investigation, recognition of these symptomatic, "superficial" factors, naturally suggests that the worker was responsible for the accident.

Investigators often believe their aim is to determine unsafe acts and conditions, implying that uncovering these will expose the reasons for accidents. Therefore, investigators often do not pry for more in depth information, leaving them to base conclusions on superficial data. Compelled to take action, punishment of the "guilty" appears to be the only solution.

Another general problem is agitated supervisors who want to complete the accident investigation as soon as possible. Punishment is normally the way of least resistance.

According to certain specialists accident investigations should be performed to ascertain the reasons for accidents in order to establish and implement appropriate remedial action(s) to prevent a recurrence.

According to Minerisk Australia (1995), accidents frequently occur as a result of deficiencies in the management system and as such they decrease performance and production. This publication informs that accidents should be used as a window through which the existing management system is viewed. The deficiencies revealed and benefits derived should go far beyond rectification of the so-called immediate causes of the accident. The investigation needs to identify the areas where managers or supervisors have unsuccessfully assumed responsibility.

In Practical Loss Control Leadership (1996), Bird and Germain describe Ferdinand Fournie's survey of 4 000 managers, supervisors and company presidents. Thirteen factors were cited for subordinates' failures to follow rules, most of which were not "punishable offences." Clearly, workers who face "obstacles beyond their control, .... think they are performing a task properly" or are "personally unable to do it", do not deserve punishment (Bird and Germain 1996: 423-425).

Management should strive to correct management systems. Inappropriate management systems normally do not anticipate or discover factors before they contribute to accidents. It is believed by some, that with few exceptions, accidents are ultimately the result of management system failures, not employee infractions. This researcher believes that this is too simplistic an approach and that a combination of factors contributes to accidents.

The outcomes of many modern industrial accident investigations do not achieve the desired effect, as the focus is limited to establishing only some of the fundamental contributing factors. Some systems in use maintain a focus on establishing blame.

In many cases, management or the authorities utilises an investigation system that only lends itself to punishing the so-called "guilty party", who may well already have experienced personal injury.

To achieve some sense of justice for a breach of standard or regulation, this type of investigation is still justified by the ill informed.

On many mines the employees involved in causing accidents are still being suspended, demoted, dismissed or otherwise punished for the "crime" of being involved in occupational accidents, according to Speir and Richard (1998).

Invariably companies complain about ineffective or unsatisfactory accident investigation programmes. In the author's opinion, they are doomed to repeat the same investigation for the same transgression again and again, with no hope of resolving the fundamental contributing factors that may lead them to preventing future accidents. The tragedy is that these firms mean well, they are trying to gain control over the factors contributing to accidents, but do not understand enough about accident prevention theory to react properly.

© 2009 Carl Marx