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People with a blame mentality are much more interested in singular causes. They prefer to name an individual or group responsible for the problem. Blame focuses on a single root cause while prevention recognizes the system of causes (refs. 1, 7). Developing a culture focused on prevention raises concerns in some managers that people will not be held accountable. In practice, a prevention culture actually raises accountability within an organization because buckets like “human error” will no longer be allowed for dumping issues when inadequate analyses are performed. People make mistakes in organizations every day, but human error is only a general category that tells us a person was involved. It does not tell us the causes of the incident. This is important to emphasize. If someone closes the wrong valve in a facility some groups will classify that issue as human error, which provides no specific information as to why the person closed the wrong valve. The prevention approach focuses on the specific causes, such as “they closed the wrong valve because they didn’t follow the procedure.” And the next question is “Why?” Human error, since it is a category, does not fit on a Cause Map. Cause Maps contain the specific causes of an incident. The Cause Maps force management to ask questions like, “Why did we, as an organization, have someone in that job at that time that did not understand closing that particular valve under those conditions would create this problem?”
Sabotage does occur, but the overwhelming majority of most problems are unintentional. If we’re late for a meeting it’s a lot easier to blame someone or something rather than identify all of the causes that were within our control to not be late. Pointing fingers at other departments only undermines the systems view of prevention. The organization must truly demonstrate that it’s interested in preventing issues from occurring. “Who did it?” is less important than the specific causes. Therefore, the focus should be on the causes not the names of individuals involved. Much of the Cause Mapping approach and problem solving in general is about better communication within our organization. This means better communication between people on what they know about the issues that affect the businesses goals. There are many people that play important roles in reducing incidents and problems, but don’t forget the people closest to the work. They are one of the best resources for both identifying causes and providing solutions - get these people involved in this prevention process (refs. 2, 5). People must be willing to come forward with information. If they fear punishment they won’t offer what they know. The message must be prevention.
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