Don't play the blame game: Figure out the real cause of accidents

Systems thinking can help you understand and prevent accidents.

By Nancy Leveson

An often-claimed "fact" is that operators or maintenance workers cause 70–90% of accidents. It is certainly true that operators are blamed for 70–90%. Are we limiting what we learn from accident investigations by limiting the scope of the inquiry? By applying systems thinking to process safety, we may enhance what we learn from accidents and incidents and, in the long run, prevent more of them.

Systems thinking is an approach to problem solving that suggests the behavior of a system's components only can be understood by examining the context in which that behavior occurs. Viewing operator behavior in isolation from the surrounding system prevents full understanding of why an accident occurred — and thus the opportunity to learn from it.

We do not want to depend upon simply learning from the past to improve safety. Yet learning as much as possible from adverse events is an important tool in the safety engineering tool kit. Unfortunately, too narrow a perspective in accident and incident investigation often destroys the opportunity to improve and learn. At times, some causes are identified but not recorded because of filtering and subjectivity in accident reports, frequently for reasons involving organizational politics. In other cases, the fault lies in our approach to pinpointing causes, including root cause seduction and oversimplification, focusing on blame, and hindsight bias.

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