This phrase, or variations on it, is one we hear a surprising number of times, usually as an explanation for why something has gone wrong. Now, we believe that

you get the team you deserve

and so when we hear these accusations, we tend to look closely at the person making those comments.

We once got asked to look at why a fork lift truck driver had hit a stanchion. The perceived wisdom at the site was that the FLT drivers were careless and could not care less. This is never a view we adopt – no one ever comes to work intending to do a bad job, so something else must be going on.

After spending a short amount of time observing the FLT drivers approaching a conveyor to remove pallets of product and witnessing the rate at which this had to be done, the close proximity the FLTs had to be to stanchions and equipment, the lack of visual cues for proximity and clearance, the slippery floor covered with starch powder, and the exposed and vulnerable equipment, the question very quickly became not “Why did that driver hit the stanchion” but “Why is that stanchion not hit more often!”.

And this is one of the secrets to good Root Cause Analysis and Incident Investigations – putting oneself in that situation and relating to the person who got it wrong. Often this will result in a feeling of “But by the grace of God there go I”, and so now we start to change how we view incidents. If we think we would likely have been caught out the same way, done the same thing, had the same incident, then blaming the operator and calling him an idiot ceases to be an option.

Instead, we have to look elsewhere.

We have to look at the environment the person is placed in. We have to look at the training provided for them. We have to look at the pressures they are under. We have to look at the visual aids and job aids that help reduce the error rate.

We also have to look at the decision makers and decisions that created the workplace environment that caused the incident and into which a worker was placed. So, next time someone gets pointed at and labelled an idiot for causing an incident,

remember there are three accusing fingers pointing back.