I'm interested in confirming or refuting (edit)

by Jay, San Diego, Monday, April 18, 2011, 09:24 (5547 days ago)
edited by Jay, Monday, April 18, 2011, 10:03

the idea that this is a collective responsibility, not an individual one.

I have seen a lot of industrial accidents in my line of work over the years. Sometimes there was someone fucking around, or not following instructions, or drunk, or willfully negligent (despite proper training and solid procedures). Those people usually hang, if not injure or kill themselves or others.

In one case, a guy just ignored his pre-op checklist and activated a flow without checking to see if there were any stop-work alerts. Turns out there were two welders inside the pipe at the time. They were lucky to live. Another case involved a guy so lazy he didn't bother to double-check his paper work, and ending up sending five tons of hazardous waste to a public landfill. That guy went to jail.

In both those cases the procedures were crystal clear and the training was completed and certified. In both cases an individual truly fucked up.

Most of the time, however, the point of failure is more nebulous, and can't be tracked down to a single person. The operators were doing everything according to their procedures, but the procedures were outdated. Or there was a situation not covered in the procedures, and nobody knew how to react. Or there was equipment failure. Or poor or muddled communication resulting in some kind of mishap, despite a commitment to safety on the ground. Despite sometimes grave (and mortal) consequences, the cause cannot be traced to a single point of failure. This is much more common. And it is not to absolve the organization of responsibility, but to reflect the truth of the matter: yes, oftentimes things were preventable, and will absolutely require an organizational review, response, practical changes, and depending on the outcome, compensation. But pinning the blame on one person would not only be not truthful, but also not helpful to the rest of the organization in assessing the cause and preventing the next accident.

It can be dangerous for the organization to simplify it. If people think it's because of one person's actions, they're less liable to check themselves. "Well, the reason that happened is because Joe is a screwup -- that would never happen to me." That's a horrible dynamic to occur, for the entire organization.