The scenario described by Ken about rushing to judgement reminds me of a situation I encountered with my previous employer (one of many  reason I decided to leave after 18 years of employment) involving a sensitization of an employee to formaldehyde. The knee jerk reaction by the immediate supervisor and Human Resources was to blame the employee and dismiss the employee for a condition clearly covered under the OSHA Formaldehyde Standard requiring the removal from exposure and reassignment to a different position where further exposure to formaldehyde would not occur. Seems to be a trend and typical response in most accident/exposure investigations where the focus should be prevention, education and taking corrective action to prevent recurrence rather than to blame. After 35 years in the health and safety profession, little has changed in managements focus and response to these types of situations. We need to keep reminding ourselves that the primary objective of our roles in to educate, prevent and engineer out employee exposures to injurious situations in the workplace, not find someone to blame. Thank you all for your continued efforts in this regard.

This is a wonderful post.  I will be distributing this message (in which I firmly believe and since I am a fan of both James Reasons and Ralph Stuart)

to both those I work with and family members as well.

Sorry I messed Ralph's presentation yesterday.

Ken 

Ken Kretchman, CIH, CSP   Director, Environmental Health and Safety

NC State University / Box 8007 / 2620 Wolf Village Way / Raleigh North Carolina 27695-8007

Email: Ken_Kretchman**At_Symbol_Here**ncsu.edu / Phone: (919).515.6860 / Fax: (919).515.6307

On Wed, Aug 22, 2018 at 6:28 AM, Ralph Stuart <000005bc294e9212-dmarc-request**At_Symbol_Here**lists.princeton.edu> wrote:

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.

- Ralph

http://www.safetydifferently.com/rush-to-judgment/

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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