July 18, 2019, 4:40 pm

The Importance of a No-Blame Culture for Safety and Reliability Improvement

This article has been prompted by the recent dismissal of a rail employee for failing to follow a standard operating procedure, resulting in a significant derailment.  The key questions here are:

  1. How likely is this to reduce the likelihood of similar, future events?
  2. What impact is this likely to have on the identification of future opportunities for reliability and safety improvement?

These should be the intent of any incident investigation, and this article will argue that dismissing the employee, in the absence of any other improvement actions, will, at best, most likely have no sustainable effect on achieving these objectives and, at worst, will inhibit future safety and reliability improvement initiatives.

I should point out that I am not privy to the specific details of the incident that prompted this article, and there may be exceptional circumstances relating to this specific incident which merit the punishment meted out, but as a general rule, we need to be very careful in using punishment as our first and primary response to any safety or reliability incident.

 

Read the full article.

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