I literally just had a conversation with someone, who told me about a serious near-miss incident.  An incident so close to deadly for one person it gave me shivers.  Thankfully they weren’t badly hurt.  The trouble was after that happened, someone else died.  This is the story of the relationship between blame and learning.
Hey, it’s Andrew, and this is Safety on Tap.
Since you’re listening in, you must be a leader wanting to grow yourself and drastically improve health and safety along the way.  Welcome to you, you’re in the right place.  If this is your first time listening in, thanks for joining us and well done for trying something different to improve! And of course, welcome back to all of you wonderful regular listeners.
Let me explain a little more, with the details which will help you better understand this situation, and the sense which emerges from nonsense.
A crew of a handful of people are highly trained and experienced in undertaking rather a high-risk work.  The risks of this work are very well known, and the controls are very well established.  One member of this team suffered an injury, which had the potential to kill him, without a shadow of a doubt.  The actual consequence was far less severe, which is a blessing for that man and his family.
It’s what happened next which started as intriguing, and ended in disturbing.  Immediately after the injured person was treated, he and his entire crew were stood down, suspended from work.  An investigation commenced, and their suspension would continue until the outcomes of the investigation were known.  This went on for a week, then a month, then another month, and another.  Many months go by, the suspension remains in force, the investigation continues at what would appear to be an elderly snail’s pace.
Now these crews, being highly skilled and trained, often operate quite collectively, with a high level of autonomy and quite informal power structures even though there are formal roles for supervisors.  One person had primary responsibility for controlling the high-risk elements of the job, the one where his mate was almost killed, the one which triggered the entire crews’ suspension from work that continued for months on end.
He killed himself.  The guy with primary responsibility for this high-risk job killed himself.
Suicide is a serious and devastating thing. I’m not suggesting that we know, that anyone knows the things which are going on prior to suicide. It is a complex issue and rarely based on a single trigger or cause. I am not suggesting the scant details here alone are connected to or triggered this tragic outcome.  But we must consider the potential effect of decisions, especially in situations like this.
If you follow or even know a little about some of the newer philosophies informing safety practice, you will be familiar with a focus on improving learning, and the role of blame in how leaders respond.  Often, you will hear a phrase like “you can’t blame and learn at the same time”, this is the sort of thing Todd Conklin says.  The visual metaphor for this is a coin, with two sides – blame on one, learning on the other.  You can’t land on both.
The thing is, this is true within a narrow context.  In the context of an incident, if you want to blame, you won’t learn.  If you want to learn, blame has no place.  In this tragic story, the response to the incident was to blame, even if those words weren’t used that is the practical effect of the actions.
But in a much broader context, looking at an entire system at work, learning is always happening.  Listen to episode 36 with Charles Jennings, where we explore the 702010 concept of learning, which explains that the majority of learning comes from experiences and social interaction.  Life is learning, learning is life.
Even when we don’t intend to teach, it happens.  The word didactic means intending to teach something – this podcast is didactic.  But our words and our actions teach, and thus learning happens to people exposed to them, whether we intend it or not.  We are responsible for it either way.
The kind of learning I am talking about here is not ‘lessons learned’ from an incident, but a much broader concept of learning.  So what learning was happening with this crew, and the organisation exposed to the actions of senior leaders who stood the crew down?
 – Around here, if you get hurt we will patch you up but treat you like a criminal in a despotic regime, guilty until proven innocent.
 – We assume you are a bad apple only when something has gone wrong, we will put you on a shelf, and inspect you at some unspecified time down the track.
 – Even when we know almost nothing about what happened, if you are even remotely connected with the incident, you will be guilty by association, the apples in the same barrel.
A while ago I was chatting with an offshore drilling superintendent, the guy responsible for managing an entire offshore drilling rig bringing millions of liters of oil from beneath the sea to the surface.  This work is some of the most dangerous in the world.  We were discussing the relationship between blame and learning.  I was curious about his experiences after incidents had happened in the places he had worked.
“Window or aisle seat,” he said.  “Window or aisle seat…?” I replied, a little confused.  “Window or aisle seat is the only question we ask a person – if you F up here, we will put you on the next chopper home, you are gone”. 
The thing is, in these circumstances, when we send people away, or when people choose to leave, our best source of knowledge about the messy reality of work and what went wrong and what we might do to prevent it happening again – that walks right out the door, of flies off an oil rig in a chopper.
Now if you aren’t with me so far, let’s get specific and talk quickly about what the evidence says about what life is like when you are not at work, away from work, an absence of work:
 – We know, with a great deal of confidence, that our need for socialisation is often largely fulfilled at work – after all, we spend a lot of time there.  We know that social isolation has a bunch of bad impacts on our health, which is best illustrated in elderly people.
 – We know, with a great deal of confidence, that in a population, people who work have better outcomes than people who do not work.
 – We know, with a great deal of confidence, that people who reduce or stop work as a result of an injury will have better life-long health outcomes and financial outcomes if they can return to as normal as possible work as quickly as possible.
 – We know, with a great deal of confidence, that when people cannot work because they are subject to decisions and systems outside of their control (like the workers compensation system), they suffer poorer outcomes than when they have more control over what is happening to them as they progress towards a return to work.
 – We know, with a great deal of confidence, that mental health declines and mental illness worsen when people at work are subject to situations in which they have no control over what is going on.
 – We know, with a great deal of confidence, that prolonged worklessness (which is an absence of work, not just an absence of a job) increases a range of health risks for that person, and decreases their lifelong chance of ever working again.  Not only that, the effects of this worklessness affects their children, in the form of poorer health and future worklessness for the entirety of their child’s life.
When that senior leader made the decision to stand that crew down, what did they expect would happen?
So what people like Conklin are trying to say, I think, is that we can’t learn in a beneficial way about a specific situation if we blame in the specific situation.  But our actions, our responses, are instructive, they teach, they create an organisation which learns how unpleasant it gets when bad stuff happens.  And senior leaders wonder why they are surrounded by good news fairies, and bad news never rises up to them.
So my two propositions to you are these:
    1. An organisation learns from every action, including blame.  The lessons from blame include mistrust, lack of care, toxicity, poor communication, and ultimately, a more dangerous operation.  Yes, the blame is a hazard, and it’s consequences are in some cases severe.


  1. An organisation which wants to learn in a beneficial way to improve, cannot blame.  Blame cannot have a place.
To be honest with you, this is a rant.  I am sick of the status quo, the way that safety directly or indirectly drives atrocious behaviour as you’ve just heard about.  This isn’t benign behaviour either, it is malignant, like cancer that spreads.  And we all have contributed to this, safety has blood on its hands, in the language we use, in the processes we write and follow, in the way we advise or fail to advise our leaders courageously.  I’m angry.
This is why I do the work that I do.  I talk a lot about learning in the context of professional development, but I spend a large chunk of my time helping organisations develop their organisational capacity to learn better.  In particular, after an incident, if you were the worker, would you rather contribute to an appreciative inquiry, which respected your expertise and humanity as a valued contributor to improvement, or would you rather participate in an investigation, grilled with interviews and questions, suspended from work, treated like a suspect whose behaviour is so often cited as the cause, but is merely the last symptom of an imperfect system of work?
We must change the way we do safety, in particular, the way we respond when something goes wrong.  Yes, I’m talking to you, you need to change.  If you want to do so, check out episode 77 with Bob Edwards on better learning, and episode 106, which draws out some more of the argument that blame just doesn’t help anyone and the alternatives to blame and retribution are much more appealing.
If you only share one Safety on Tap episode ever, please make it this one.  Please share this story with people who would benefit from learning what happens when blame drives behaviour and beneficial learning disappears.  Share it with your boss, share it with your colleagues, with your HR manager, with your operations manager, with your CEO.  Use this to drive forward, weaponise this episode for good.
Finally and most importantly, if you are experiencing challenges with your mental health or thinking about suicide, or know of someone who is, please reach out for help.  Since we have a global audience I can’t list all the possible places you can get help quickly, but the internet can.  Click here for a directory of services, or you can easily google suicide hotlines in your country and get help.
Thanks so much for listening.  Until next time, what’s the one thing you’ll do to take positive, effective or rewarding action, to grow yourself, and drastically improve health and safety along the way? Seeya!

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