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Blametropism

Tom Geraghty · Power, Safety & Human Error

Coins 'blametropism' (from the Latin tropus, a turning or affinity) for the common, possibly ubiquitous human instinct to turn toward individual blame even when it is neither accurate nor useful. Opens by puncturing the myth that psychological safety means a 'blameless' culture: blame can occasionally be appropriate — for deliberate theft, or where someone causes harm with both the intention (mens rea) and the action (actus reus) — and upholding high standards of behaviour actually supports PS by making the unacceptable explicit. The problem is our default to blame where it doesn't fit. In complex sociotechnical systems an incident is almost always a compounding of technical, environmental and human factors, yet investigations too often conclude simply that 'the human did it' (Hollnagel and Woods: since no system builds, operates or maintains itself, the search for a human in the path of failure is bound to succeed). Two questions matter: is the blame fair, and is it useful? Usually neither. Blame draws on the fundamental attribution error (overweighting disposition, underweighting context) and the ultimate attribution error (assigning the failures of marked or minority identities to group traits), making it frequently unjust; and stopping at 'blame the human' forecloses the question of why the human did what they did, losing the chance to learn and prevent recurrence. Defines blame as 'accountability without context', and argues for being 'blame-aware' rather than naively blame-free: acknowledging our blametropic instinct, keeping the local rationality principle in view, and treating errors as information about the system. Justice is a real but secondary concern after learning and improving.

Connected concepts (51)

• Behind Human Error: Cognitive Systems, Computers, and Hindsight (paper)
• How Complex Systems Fail: Being a Short Treatise on the Nature of Failure, How Failure is Evaluated, How Failure is Attributed to Proximate Cause, and the Resulting New Understanding of Patient Safety (paper)
• Organizational Errors: Directions for Future Research (paper)
• Out of the Crisis (paper)
• Power, Approach, and Inhibition (paper)
• Strategies for Learning from Failure (paper)
• The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA (paper)
• Who Gets to Decide if PS Matters?
• Accountability
• Accountability: The Neglected Social Context of Judgment and Choice (paper)
• Failing to Learn and Learning to Fail (Intelligently): How Great Organizations Put Failure to Work to Innovate and Improve (paper)
• Human Error: Models and Management (paper)
• Learning from Mistakes Is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error (paper)
• Local Rationality
• Normalisation of Deviance (Challenger)
• PS is Political
• The Criminalization of Human Error in Aviation and Healthcare: A Review (paper)
• The Intuitive Psychologist and His Shortcomings: Distortions in the Attribution Process (paper)
• The Possibilities of Accountability (paper)
• Typologies of Power
• Why Hospitals Don't Learn from Failures: Organizational and Dynamics That Inhibit System Change (paper)
• A Question of Trust (paper)
• HOP
• Just Culture
• Learning from Error
• Moving off the Map: How Knowledge of Organizational Operations Empowers and Alienates (paper)
• Soft to Each Other, Hard on the System
• Taming Prometheus: Talk about Safety and Culture (paper)
• The PS Observer Effect
• The Unintended Consequences of No Blame Ideology for Incident Investigation in the US Construction Industry (paper)
• Academic Fraud & Data Dishonesty
• Amagasaki Disaster
• Black Swans, Cognition, and the Power of Learning from Failure (paper)
• Burnout & PS
• Chernobyl
• Dr Richard Cook
• Fundamental Attribution Error
• How Not to Investigate an Accident (paper)
• Human Error & PS
• Individual Resilience
• PS, Just Culture & Met Police
• The Lived Experience of Accountability: A Phenomenological Study in Maritime Safety (paper)
• What Not to Say
• Whistleblowing & PS
• You Can't Fix a Secret
• At the Heart of Morality Lies Folk Psychology (paper)
• Bad Management
• Mining for Root Causes
• Overcoming Toxic Work Culture
• Understanding Variation
• Safety, Stat!