Beyond Blame

Chapter 18. The Learning Review Framework

1. Set the context.

   • The purpose of the learning review is to learn so that we can improve our systems and organizations. No one will be blamed, shamed, demoted, fired, or punished in any way for providing a full account of what happened. Going beyond blame and punishment is the only way to gather full accounts of what happened—to fully hold people accountable.

   • We’re likely working within complex, adaptive systems, and thus cannot apply the simplistic, linear, cause-and-effect models to investigating trouble within such systems. (See A Leader’s Framework for Decision Making by David J. Snowden and Mary E. Boone.)

   • Failure is a normal part of the functioning of complex systems. All systems fail—it’s just a matter of time. (See How Complex Systems Fail by Richard I. Cook, MD.)

   • We seek not only to understand the few things that go wrong, but also the many things that go right, in order to make our systems more resilient. (See From Safety-I to Safety-II: A White Paper by Erik Hollnagel, et al.)

   • The root cause for both the functioning and malfunctions in all complex systems is impermanence (i.e., the fact that all systems are changeable by nature). Knowing the root cause, we no longer seek it, and instead look for the many conditions that allowed a particular situation to manifest. We accept that not all conditions are knowable or fixable.

   • Human error is a symptom—never the cause—of trouble deeper within the system (e.g., the organization). ...