This new blog post addresses the issue I raised in my presentation yesterday relative the challenge presented in developing "Lessons Learned" from safety incidents. Organizational investigation practices often lead to simplistic conclusions about complex situations... I've excerpted the opening paragraphs from the complete article.
RUSH TO JUDGMENT
In our rush to judgment we rarely intend to do harm. Often, we react to incomplete or even scant information, fit it into our own mental model of how things should be and then jump to conclusions that could inflict harm.
Last week, CBS Morning News showed a film clip of a man snagging a baseball from a kid who was sitting directly in front of him. The less than 10 second clip resulted in the vilification of the man as a bully who stole the ball from the little kid. One day later the same news show provided an apology to the man for jumping to judgment. Why the change? Simply put, the news media learned the context around the actions and found that the man had caught and given away several balls to those around him including the boy in front of him.
Context is something that helps us to walk in the shoes of others - but it takes time and effort to learn context. Often it is much easier to live in a land of blame and shame. Our organizational responses to incidents and accidents have followed the same path and resulted in investigation reports that name individuals as the cause of accidents without a mechanism that helps the investigator to learn or discover context.
Our tendency is to oversimplify - enter the concept of requisite variety, which implies that the complexity of our assessment of systems has to meet the complexity of the systems that we are scrutinizing. Yet, so many of our processes are not designed to embrace complex systems.
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