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A Review of Literature: Individual Blame vs. Organizational Function Logics in Accident Analysis

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When an accident happens in an organization, two different approaches are possible to explain its origin and dynamics. The first approach, called individual blame logic aims at finding the guilty individuals. The second approach, called organizational function logic aims to identify the organizational factors that favoured the occurrence of the event. This article compares the two different logics of inquiry, the consequences that they produce, in particular in the case of accidents caused by unintentional actions. Though favoured by the scientists, the organizational function logic approach is in real life usually beaten by the individual blame logic. Reviewing the literature, this article brings together the arguments for using the organizational function logic from the perspective that learning from accidents is necessary to prevent them from happening again.
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A Review of Literature:
Individual Blame vs.
Organizational Function Logics
in Accident Analysis
Maurizio Catino
Department of Sociology and Social Research, University of Milan – Bicocca, Via Bicocca degli Arcimboldi 8,
20126 Milan, Italy. E-mail: maurizio.catino@unimib.it
When an accident happens in an organization, two different approaches are possible to
explain its origin and dynamics. The first approach, called individual blame logic aims at
finding the guilty individuals. The second approach, called organizational function logic
aims to identify the organizational factors that favoured the occurrence of the event. This
article compares the two different logics of inquiry, the consequences that they produce,
in particular in the case of accidents caused by unintentional actions. Though favoured by
the scientists, the organizational function logic approach is in real life usually beaten by
the individual blame logic. Reviewing the literature, this article brings together the
arguments for using the organizational function logic from the perspective that learning
from accidents is necessary to prevent them from happening again.
1. Introduction
Accidents and disasters in organizations are shock-
ing events for society. These events call for an
explanation. As Weick puts it: ‘A cosmological episode
occurs when people suddenly and deeply feel that the
universe is no longer a rational, orderly system. What
makes such an episode so shattering is that both the
sense of what is occurring and the means to rebuild that
sense collapse together’ (Weick, 1993, p. 633). Roux-
Dufort associates to this fact the notion of the neces-
sary cosmogonic explanation after crisis. ‘Literally the
term cosmogony means a mythological account about
the origin of the universe and its components. The
Bible’s Genesis is a cosmogony. [. . .] The event seen as a
cosmogonic episode therefore implies that it sheds light
on its consequences and its origin’ (Roux-Dufort, 2007,
p. 110).
There are two distinct approaches possible for the
explanation of the origin and dynamics of an accident,
which usually lead to different conclusions. When we
speak of accidents in this article they are by definition
the result of unintentional acts.
The individual blame logic (IBL) is an accusatory type
of approach which tries to identify the guilty individuals.
This approach is typical of criminal law, but is also
prominent in organizations based on a punitive culture
(Avery & Ivancevich, 1980). More generally, this ap-
proach fits in with the wish of society to identify a clear
cause for the accident (Helsloot, 2007).
The organizational function logic (OFL) is an organi-
zational and functional type of approach which intends
to identify the factors within the system which favoured
the occurrence of the event. In this second approach,
once these factors are removed, it is hoped that similar
events cannot happen again or that they will occur less
frequently and less probably.
The two approaches are characterized by two dis-
tinct inquiry logics which generate different conse-
quences.
A central aspect in this article is the measure in
which both approaches give the possibility to learn from
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9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main St., Malden, MA, 02148, USA
Journal of Contingencies and Crisis Management Volume 16 Number 1 March 2008
the accidents under investigation. The subject of learn-
ing from accidents is a relevant theme in a risk society
(Beck, 1986; Luhmann, 1991) with its seemingly endless
series of emerging risks.
As a preliminary remark it must be noted that the
OFL itself consists of more than one way to conduct
inquiries and organizational analyses in the case of an
accident. Well known is the explanation that the school
of Normal Accident Theory (Perrow, 1999; Sagan, 1993)
gives for the analyses of accidents, i.e., accidents are
‘normal’ in certain technical and organizational con-
texts. Another classical approach within the OFL is the
High Reliability Theory (Roberts, 1990, 1993; Weick,
1990; Weick, Sutcliffe, & Obstfeld, 1999; Weick &
Sutcliffe, 2001), where an area of tangible improvement
of organizational reliability is identified in the manage-
ment processes. The inquiries of major accidents like
those of Weick for the Tenerife accident (1990), and of
Vaughan for the Challenger accident (1996) are a point
in case. An interesting attempt to combine both view-
points was made by Snook (2000). For a critique of
both approaches see Marais, Dulac, & Levenson (2004),
and for a discussion of more approaches within the OFL
see Catino, 2006.
The objectives of this article are:
1. to compare the two inquiry logics IBL and OFL. On
the basis of the inquiry logics followed, different
‘facts’ can emerge;
2. to highlight the ‘perverse effects’ IBL may have in the
sense that by searching for the individual responsi-
bility IBL prevents real learning, thus, is unable to
improve the system;
3. to evidence how the OFL, which is oriented on
learning and thus preventing accidents, reinforcing
safety and improving resiliency, does not have in-
stitutional legitimacy as IBL, and therefore its merits
remain unheard;
As an introduction the following case based on an
real accident is presented.
1.1. The accident
Mr. X is 65 years old when he is hospitalized for an
emergency on Saturday morning for the fracture of his
femur. His general condition is good, though he has had
rheumatoid arthritis for several years. Upon entering
the hospital he informs Dr. First, the admitting physician,
that he is being treated with Methotrexate (Mtx), two
vials of 500 mg per week. Dr. First asks Mr. X and his
daughter who is a nurse, for a copy of the prescription.
Meanwhile, he writes what the patient told him on the
patient case sheet. Mr. X is admitted to the ward which
lacks the vials of Mtx 500 mg; they are ordered from the
internal pharmacy. In the meantime, the daughter of
Mr. X confirms what her father said in admittance,
providing neither written documentation nor his med-
icine from home. Two days later, Dr. First goes on
vacation leaving the ward to Dr. Second who visits the
patient daily. Dr. Second correctly copies the prescrip-
tion (two vials of Mtx 500 mg once a week). The
following Wednesday, he treats the patient with the
first dose of Mtx. The anaesthetist visits Mr. X, controls
the therapy and signs the authorization for surgery. Mr.
X undergoes surgery (endo-prothesis) and afterwards,
a second dose of Mtx. Unexpectedly, the general
condition of the patient worsens: his temperature
reaches 38.51C with marked asthenia. A possible infec-
tion is suspected because of the operation and a broad
spectrum antibiotic therapy is started; at the moment
no one considers the dosage of Mtx, nor the doctors
on duty, or the intern. On day 8, the general condition
of Mr. X worsens even more; his fever rises above
38.51C with marked asthenia, leucopenia and granulo-
cytes. He is transferred to the infectious diseases ward,
where he is treated with folic acid for suspected
septicaemia. On the 11th day after being admitted to
the hospital, Mr. X dies.
1.2. The quest for an explanation
What happened? What was the error? The facts which
can be straightforwardly collected are these: the drug
Mtx is used to treat rheumatoid arthritis, but in doses
of 5 mg and not 500mg, as was used. At this level it is
used to treat malignant tumours, but it must be
administered together with drugs like folic acid, which
are able to reduce the harmful effect of Mtx on the
production of white blood cells. Mr. X was treated with
a dosage 100 times superior to what was necessary for
him and the error of the dosage was not noticed:
1. by Dr. First,
2. by Dr. Second,
3. by the doctors on duty in the afternoon,
4. by the anaesthetist,
5. by the intern,
6. by the pharmacy.
Considering the case from the perspective of the IBL,
the central question is: Who has made a mistake and
who has made the most prominent mistake?
Considering the case from the perspective of the
OFL, the central question is what are the organizational
factors that favoured this mistake? It then is clear that
the collected facts are not sufficient to answer this
question.
54 Maurizio Catino
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2. The two approaches presented
In this section both the approaches are presented.
2.1. IBL
The starting point for the IBL is the assumption that
people make mistakes because they do not pay enough
attention to the task they are doing. It, therefore, adopts
a causal linear model leaving the organizational context
mostly in the background. The efforts to find the blame
are as a result directed to people in the front line, and
the result of the approach is the attribution of the blame.
If the guilty person is found, he or she can be held
responsible for the accident. In practice this may mean
that the ‘bad apple’ will be removed or prosecuted.
The IBL is based on some ‘good reasons’ (Boudon,
1992): beliefs that are valid for making decisions and
carrying out the choices made. These beliefs indicate
what the actors consider right in certain circumstances,
to behave as they behaved. Referring to Reason (1997)
the IBL, is based on some of the following beliefs:
1. Voluntarity of actions. People are considered as free
agents capable of choosing between safe and unsafe
behaviour. As demonstrated by numerous research
reports, human actions are implicated in 80–90% of
accidents and because human actions are perceived
as subject to voluntary control, then accidents must
be caused by negligence, inattention, inaccuracy,
incompetence, etc.
2. Responsibility is individual. The personal based model
is based on a conception of individual responsibility.
As in criminal law, the personal approach searches
for the person who is responsible for the error.
3. Sense of justice is strengthened. The IBL is emotionally
satisfying; after a serious error, or worse a disaster,
the identification of the blame tends to satisfy the
people involved and the public in general.
4. Convenience. Basing the responsibility on the indivi-
dual undoubtedly has advantages for organizations
from the legal and economic point of view, also
because it lets them maintain their organizational
structure, their rules and their power system un-
altered.
The IBL is in agreement with the Western legal system.
Gherardi (2006) says that safety, from the legal per-
spective, is a matter of individual responsibility and a
potential source of liability and punishment. The goal of
criminal law is in other words to identify the respon-
sible individual and to allocate adequate punishment for
the type of crime committed.
The search for who is responsible tends to focus the
inquiry towards the identification of one or more
people who committed the error. These people who
activate the accident are often the front line operators
of the complex human–machine system. It is obviously
easier to identify a person who is in close contact with
the system (the pilot of the plane, the physician, the
nurse, the control panel operator, the train conductor,
etc.) who is responsible for the event, rather than the
hidden factors of the organizational and managerial
aspects which are the product of collective actions
diffused in time.
2.2. The OFL
There is an increasing recognition that mishaps are
inextricably linked to the functioning of surrounding
organizations and institutions (Dekker, 2005). The OFL
is based on the assumption that failure is part of the
human condition, and if we cannot change the human
condition, then conditions under which human beings
work can be changed (Reason, 1997). The organiza-
tional model views human error thus, more as a
consequence than as a cause (Reason, 1997, p. 226).
If the IBL leads to the identification of the person
who is responsible for the event, the OFL instead leads
to the identification of the latent factors
1
and critical-
ities that are at the origin of the accident. Remedying
this can keep other accidents from happening in the
future. The OFL therefore reconducts the causal
factors of an event to the whole organization. It
acknowledges that accidents are the result of mistakes
made by individuals, but these mistakes, however,
are socially organized and systematically produced
(Vaughan, 1996). From this approach, accidents are
derived from a connected sequence (usually rare) of
defects in numerous defense systems, safeguards, bar-
riers and controls to protect the organization from
unknown hazardous events.
OFL approaches usually distinguish the ‘active errors’
which activated the accident committed by the opera-
tors closest to the task, from ‘latent factors’ under-
stood as organizational criticalities which made the
accident possible, or sometimes caused it: temporal
pressures, equivocal technology with ambiguous man–
machine interfaces, insufficient training, insufficient sup-
port structures, a work atmosphere which is not safety
prone, unclear procedures, communication problems
and still other factors (Reason, 1990, 1997). It is
obvious that the human factor is the element which
directly induces an accident in most cases, but the
human factor is only the first order cause
2
of the accident
history where history is completed through the analysis
of the entire sequence of events and of the latent and
pre-existing organizational factors (Catino, 2006).
The main idea of the OFL is to shift from the
individual causes to the understanding of the accident
in terms of ‘reasons’, of why the events and the errors
Who is to blame? Inquiry logics in accidents analysis 55
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occurred (Leveson, 2004). The analyses of famous
accidents, like Chernobyl or Bhopal have shown that
these disasters were not caused by the coincidence
of technological failures and human errors, but by
the systematic ‘migration’ of the organizational beha-
viour towards the accident under the influence of
efficiency and cost reduction pressures in aggressive
and competitive environments (Rasmussen, 1997). The
analysis of the disaster of Linate (Catino, 2006) points
out how the flow of events cannot be lead only to the
action, which is or is not the voluntary action of a single
operator.
This OFL approach points out the limits of a model of
linear causality. Discussing linear actions and events
which cause an accident is reductive, because it does
not incorporate the nonlinear relationships between
the events and the feedback. Such nonlinear relation-
ships are for example the commitment of management
to safety and the ‘inheritance’ of the errors and
ommissions of those who designed and manage the
operational and organizational system.
It will be clear by now that the way in which the same
accident phenomenon can appear ‘objectively’ different
under the two logics, stems from the fact that there are
two processes of different framing at work (Dewey,
1938; Shrivastava & Schneider, 1984; Dodier, 1995).
Each one selects from the abundance of facts what is
relevant for inquiry, based on the different finalities to
be pursued. What is taken into examination is only
what is considered significant in relation to the goals of
the inquiry. This leads to a different way of reconstruct-
ing the ‘truth’. The concept of ‘cause’, together with the
concept of ‘finality’, is the element which most distin-
guishes the two different inquiry logics and is also the
most controversial.
3
The two logics thus possess
different frameworks (Goffman, 1974), they operate
with different paradigms (Kuhn, 1962), and they have
different sense-making processes (Weick, 1995). The
two logics achieve a different kind of accountability: the
‘what happened’ question thus relates to a social and
institutional construction of the facts.
3. Inquiry logics: the case for OFL
As we have seen there are different criteria for the
attribution of the cause of the accident: the search for a
cause is inevitably tied to the point of view and interest
of who is making the inquiry. In this section the
arguments for the case for OFL are presented.
The central argument against IBL lays in the vicious
circle
4
illustrated here below (Figure 1).
Once the ‘guilty actors’ found according to IBL are
removed, it is very probable that the organizational
system will continue to function with the same organi-
zational conditions and mechanisms which lead to the
error and to the accident. Being principally interested in
searching individual responsibilities, the IBL creates a
sense of fear of sanctions and of legal actions. In a punitive
organizational environment the individuals refuse risks
and worry more about their own legal safety than the
safety of the user. The Institute of Medicine (USA) aims to
decrease errors in the health field by 50% in 5 years, but
as the New England Journal of Medicine observed every
effort made to prevent the damage derived from a
medical treatment is obstructed by the ‘dead weight’ of
a legal regime which induces the operators to secrecy and
to silence (Brennan, 2000). Merry & Smith (2001) again
referring to the health system affirm that working under
the threat of legal action creates an atmosphere of fear
which does not lead to the best management of people in
a medical system. The ‘demonization’ of errors prevents
physicians from admitting and discussing them publicly
because this information could be used against them in
criminal lawsuits. The legal system puts the doctor and
the patient one against the other (Gawande, 2002),
forcing both to give an unrealistic version of the facts.
Therefore, fear of legal consequences favours the fact that
errors are hidden.
Adopting the IBL, the organization is not able to
understand its own errors (Crozier, 1963; Hale, Wil-
pert, & Freitag, 1997). The result is organizational
change inertia: if one or more people are responsible
for what happens, why change things? It follows that the
persistence of a blame culture, reinforced by a certain
type of legal action, becomes the first obstacle to the
creation of greater safety. As Vaughan wrote (Vaughan,
1996, p. 392): ‘the benefit of an explanation which
immediately identifies the cause of an organizational
failure in the decision makers is that remedies are
possible quickly. The ones responsible for the accident
can loose their jobs, be transferred or be sent into
retirement. New rules which regulate decision making
can be instituted. After making these changes . . . . the
organization can go forward’.
Turner & Pidgeon (1997) affirm that the impact of the
legal system has the power to suffocate any attempt of
learning from the errors. For example, during a legal
inquiry, the organizational improvements could be
omitted or delayed because it could constitute implicit
admission of previous negligence. In this case these
improvements would show that the organization pos-
sessed elements which could have avoided the accident.
Individual Blame Logic
Search for the guilty Hidden errors
Inertia to organizational change
Figure 1. The vicious circle of the individual blame logic.
56 Maurizio Catino
Journal of Contingencies and Crisis Management
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In research from many years ago, Drabeck & Quar-
antelli (1967) supported the perfect rationality in
the identification of scapegoats following disasters and
the usefulness for the managers of identifying the blame at
the individual level. The incrimination of single individuals,
having become scapegoats, was an expedient to delay and
avoid structural changes of the organization (Douglas,
1995). Public opinion was lead to believe that the
exemplary punishment of the ‘guilty’ individual could serve
as a future deterrent.
In reference to the Challenger accident, Vaughan
affirmed that ‘this case shows why it is so difficult, for
the normative and legal system to assign the right
responsibilities when the organizations have harmful
results. It is well known that the division of labour in
organizations obscures the responsibilities of the orga-
nizational actions’ (Vaughan, 1996, p. 408). This type of
analysis runs the risk of not producing changes, but also
risks limiting itself to an extremely dangerous blame
culture. It is also true, more prosaically, that when a
single person is identified as responsible for the dis-
aster, the individual responsibility is split from the
responsibility of the organization, with overall signifi-
cant economic and financial advantages for the system.
While the IBL is not likely to produce organizational
changes, the OFL can be used for determining the
organizational conditions of the events of the accident
and removal of the latent critical factors. Above all, the
OFL looks for those critical organizational conditions
which if not removed, will continue to create risk and
error conditions independent of the people who are
operating (Figure 2).
The OFL
5
tends to substitute the question ‘who
caused the accident?’ with ‘what conditions and mechan-
isms have increased the possibilities of its happening’,
‘how and why did the defense systems fail?’, ‘what can we
do so that the event will not be repeated?’ (Reason,
1997). As ascertained by research from the last 25 years,
disasters and accidents in organizations are not generated
by a single cause but by a number of interrelated events
which taken singularly can appear to be totally insignif-
icant and not influential in the origin of the accident
(Weick, 1990; Turner & Pidgeon, 1997; Reason, 1997;
Dekker, 2005; Hollnagel, Woods, & Leveson, 2006).
However, they enter into a relationship with each cause,
and in the presence of a weak defense system, they
increase the possibility that an accident will happen.
As a detail, for the OFL, both an accident and a near
miss
6
are of equal interest, if they are morphologically
similar. The near miss in fact is weakly relevant from the
legal point of view, but crucial in the organizational
functional perspective. It informs the analysts about the
state of risk of a system, and observations of its magni-
tude and frequency is essential to understanding the
latent critical areas of an organizational system (Table 1).
The central aim of the OFL is to learn from errors
and accidents. On the basis of the lessons learned from
the event, it attempts to actively generate better
prediction ability in the operations of the organization
(Toft & Reynolds, 1994). The OFL is typical of the
‘generative organization’ (Westrum, 1995) which in its
ideal form is a thinking and self-aware organization. It is
constantly on the look out, and continuously reviews its
own procedures. A generative organization is a highly
reliable organization which never considers safety as a
condition that has been definitively achieved, but as an
objective which has to be pursued continuously (La-
Porte & Consolini, 1994; Weick et al., 1999; Weick &
Sutcliffe, 2001). The aim of the organizational functional
logic is to make organizational learning possible (Fried-
berg, 1993; Argyris & Scho
¨n, 1996) and to favour
Organizational Function Logic
Search for
organizational
criticality
Reporting errors
Removing latent factors
Organizational learning
Figure 2. The virtuous circle in the organizational functional logic.
Table 1. Inquiry Logics: A Comparative Over view
Individual blame logic Organizational function logic
Aim Identify the guilty; sanction Understand, explain, improve
Principal question Who caused the accident? What factors favoured the accident?
How and why did the defense system fail?
Concept of cause Causal linear model Cause networks; systemic approach;
latent factors
Failure concept Individual Built organizationally
Form of post-accident inquiry Judicial inquiry Organizational analysis
Context In the background; accidental; does
not exclude individual responsibilities
Structuring action
Result Only individual; removal of the bad apple Organizational and inter-organizational
Undesired effects Inertia to change; subjective attribution
of the disaster
Individual irresponsibility
Who is to blame? Inquiry logics in accidents analysis 57
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organizational change, at different levels, as well as
introducing a possible ‘clinical’ dimension. Therefore,
such an inquiry has pragmatic value,
7
in the sense that
the results can help the subject review the functioning
logics of the organizational system, improving the
knowledge the actors have of the system and of their
own context of action (Friedberg, 1993).
4. Limits of learning from accidents; the
case against a belief in OFL
‘Do human societies learn? If so, how do they do it; and
if not, why not?’ Sheila Jasanoff asks herself (2005).
Learning from a disaster is a complex, ambiguous
process – conditioned by culture, yet not easily forced
into univocal, totalizing, national narrative. Jasanoff
reconducts the different forms of disaster inquiry to a
specific ‘civic epistemology’: the styles and the mod-
alities of public inquiry, public accountability issues, the
strategies used to find the responsibilities and to
achieve obiectivity. With this useful concept, Jasanoff
intends ‘the public ways of knowing, constituted, dis-
played, and reaffirmed within the decision-making pro-
cesses of states, including those aimed at the
management of risk and prevention of harm’ (211).
Civic epistemology refers ‘to the mix of ways in which
knowledge is produced, presented, tested, verified and
put to use in public arenas’ (226). Seen in this light, civic
epistemology is a constitutive element of political
culture of risks: ‘the particularity of national civic
epistemologies lies, in part, in the boundary that each
framework constructs between factual and moral
causes or, put differently, between responsibility and
blame’ (Jasanoff, 2005, p. 212).
The organizational learning concept that is used in
the OFL is consistent with the Argyris & Scho
¨n (1996)
conceptualization of organizational learning as the
detection and correction of error. It is possible to
distinguish two learning modalities related to an acci-
dent: a passive learning approach and an active one (Toft
& Reynolds, 1994). The passive learning approach is
characterized by the acquisition of the results coming
from public investigations and related recommenda-
tions. The active learning approach needs a wider
awareness of the event and is aimed at improving the
foresight ability of the organization in the daily activities
and in facing the risks. Active learning from accidents
proves to be very difficult in real life. Many authors
(Sagan, 1993; Rasmussen, 1990; Vaughan, 1996; Turner
& Pidgeon, 1997; Perrow, 1999; Choularton, 2001;
Busby, 2006; Elliot & Smith, 2006) underline the diffi-
culty of learning from accidents and errors and how to
act in order to prevent the risk that the same errors
can occur again. According to Choularton (2001, p. 62)
in case of accidents ‘while superficial learning is com-
mon, more fundamental lessons are harder to learn’.
Busby (2006, p. 1391) affirms that ‘organizing around
risks of catastrophic failure critically involves processes
of systemic reform whose efficacy is limited by condi-
tions that organizing itself tends to produce’.
Turner & Pidgeon (1997), refering to the definition of
Wilensky (1967) who speaks about ‘failure of foreseen’
and ‘failure of intelligence’, underline the inability of the
members of an organization to recognize and become
aware of the signs of danger which transpire before an
accident occurs.
Some authors use the term ‘organizational intelli-
gence’ to refer to the capacity of an organization to
obtain and elaborate clear and reliable information
which supports the process of being aware of what is
going on. The information should be understood in the
same way by operators belonging to different profes-
sional communities. However, this usually does not
happen and the same event is considered in different
ways from different communities which work in the
same organization. There is an ‘organizational myopia’
which inhibits the analysis of signs, as well as reports
and complaints by people. There are also situations
where the signs of danger are intentionally hidden.
March (1988) underlines how successful organizations
tend to not to change their strategy, independently
from its relative value. There are many reasons for this
imperfect learning (Turner & Pidgeon, 1997). Some of
them are related to the institutional dilemma of the
blame, to the fact that danger and blame are constitu-
tive characteristics of the society, elaborated to defend
the chosen mechanism (Douglas, 1985, 1992; Douglas
& Wildavsky, 1988).
Concerning the problem of learning from accidents,
the normal accidents theory (NAT) and the high-relia-
bility theory (HRT) diverge significantly. The NAT (Per-
row, 1999; Sagan, 1993) is pessimistic and emphasizes the
limits of learning, while the HRT (Roberts, 1990, 1993;
Rochilin, 1993; Schulman, 1993; LaPorte & Consolini,
1994; Weick et al., 1999; Weick & Sutcliffe, 2001) has a
more positive outlook. According to the NAT there are
many different obstacles to learning. Sagan (1993) iden-
tifies four of them: (1) highly ambiguous feedback for
organizations; (2) learning happens in environments
which are strongly influenced by political interests, and
efforts to identify causes of an accident are addressed to
protect the personal interests of powerful people rather
than being aimed at promoting the learning process; (3)
information related to an event is incomplete and
inaccurate; (4) the non-disclosure, intended as compart-
mentalization inside the complex organizations, is the
disincentive to share information. On the contrary,
according to the HRT, serious errors can be an important
source of future safety improvements.
In an OFL the organizational learning from failures is
based on reporting error and this depends on a no-
58 Maurizio Catino
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blame culture based on a different anthropology of
error focused on the idea that learning from errors is
the only way to avoid accidents (Catino & Albolino,
2007). At the same time, learning from errors and
failures implies a ‘just culture’. The just culture can be
defined as a culture where there is an atmosphere of
trust in which people are encouraged (even rewarded)
for providing essential safety-related information, but
also in which it is clear where the line must be drawn
between acceptable and unacceptable behaviour (Rea-
son, 1997).
5. Summary
This article analyzes two different ways to consider the
accidents relating to two different civic epistemologies,
focusing on one aspect of learning: ‘the efforts to
determine a causal agent or agents in each instance,
since identifying causes is a prerequisite to any subse-
quent effort to target solutions and remedies’ ( Jasanoff,
2005, p. 212).
In a complex organizational system the simple pun-
ishment of an operator for an accident, without asses-
sing the deficiencies of the system, means favouring the
repetition of the unfavourable events also with other
actors. However, it is important to realize that the OFL
for the understanding of errors and accidents is not
without problems. Wells, Morgan, & Quick (2000. p.
503) affirm the following:
‘Given the emphasis on avoiding the individual blame
trap, there is arguably, a danger of overlooking
aspects of valid individual responsibility. At the very
least, the collective approach risks blurring lines of
accountability and avoiding necessary questions of
where responsibility should lie. It is possible that, by
skewing the emphasis in favour of wider organiza-
tional factors, errors will never be regarded as an
individual’s fault, even when they might properly be
so regarded. Further, this could erode the sense of
personal and professional responsibility. Arguably,
there are positive aspects to blaming. It is difficult
to deny the deterrence aspect of blame particularly
with legal processes’.
A criminal sanction could be effective in preventing
misconduct in deliberate actions such as fraud or
sabotage, but at the same time it is hardly effective in
cases where the operators are not able to completely
control their behaviour. It has little effectiveness in
error cases, in cases of unintentional actions. Accidents
in a complex system cannot be attributed to a single
cause. Identifying and removing the people who are
potentially implicated in the event is easier than im-
plementing the revisions of processes and organiza-
tional dynamics which generated the failure. However:
‘[. . .] we must be aware that people who are substi-
tuted will be subject to the effects of the same culture
and structure. In fact, every remedy which is limited
only to individuals leaves the structural origin of the
problem unvaried’ (Vaughan, 1996, p. 418).
To understand the dynamics of an accident it is useful
to ask if under the same conditions a different actor
would have been able to make the same error which
caused the damage. If the answer is positive, then it is
the situation which is prone to error. Investigating with
these terms the dynamics of a complex accident would
mean shifting from an IBL to an OFL based one.
Nevertheless, this passage is not easy and requires
three conditions.
The first condition is the no-blame safety culture
(Catino & Albolino, 2007) where front line operators
or others are not punished for actions, omissions, or
decisions made by them that are commensurated to
their experience and training, but are punished for
gross negligence, violations and destructive acts. It is
necessary to explain that a no-blame organization is not
an organization where everything is lawful as long as it is
declared. A no-blame organizational environment re-
quires the establishment of boundaries between actions
and blameworthy errors and between actions and
tolerable errors, so that the second category can be
as broad as possible. An organization which does not
put this distinction into effect risks loosing credibility in
the eyes of its own members.
A second condition of an OFL is to provide models
of organizational analysis and improvement suitable to
the complexity of the event. They are systemic and
organizational models that are socio-technical, which
consider accidents as being derived from the interac-
tion among people, between organizational and social
structures, within design activities and components of
the physical system (Vaughan, 1996; Hollnagel et al.,
2006). These models are focused on the different levels
involved: (a) individual (the actions of the people), (b)
organizational (work processes, the management and
organization of the context where the event takes
place, (c) interorganizational (the organizational field,
the organizations of the reference system, the suppli-
ers, the control and regulation agencies, etc.) (DiMaggio
& Powell, 1991; Catino, 2006).
The third condition relates to institutional level of
OFL. This is often a weak point. The strength of the
institution contributes in determining the effectiveness
of the prescription. As already mentioned, the judicial
inquiry is authoritative because the actions and the
decisions made by the actors are legitimized by the
society which share them, or which they consider
binding. This inquiry has formal rules, practices and
institutional conducts, administrative apparatus and
areas of action that could not be in any other way.
Who is to blame? Inquiry logics in accidents analysis 59
&2008 The Author
Journal compilation &2008 Blackwell Publishing Ltd.
Journal of Contingencies and Crisis Management
Volume 16 Number 1 March 2008
On the contrary, the inquiry used in the OFL does not
have the necessary power to begin the change which is
needed at the organizational level. The management of
the organizations involved should not give importance
to this kind of inquiry. The veto players
8
present in
the system can easily oppose the changes. For example,
the air transportation system has a broad and complex
interorganizational system composed of numerous
public and private, national and foreign subjects. The
number of veto players by definition is high. The
number of actors with veto power is high, because
they are threatened or penalized by actions of change.
Therefore, they can successfully delay or totally block
changes.
As March & Olsen (1989) sustain, the reorganization
efforts which ignore the networks of power and
interest are destined to failure and therefore remain
without consequence. Using the distinction made by
lawyers, especially those in the area of international and
European law, it can be said that the IBL inquiry to
identify responsibilities applies hard law, with alterna-
tives of legal validity of authority of binding power,
whereas, the OFL inquiry to improve the system applies
soft law producing recommendations, guide lines, and
reference points which have less authority and binding
power.
It would be useful to further investigate the institu-
tional legitimacy of different types of inquiries, identify-
ing the possibilities and the modalities of increasing the
degree of institutionalization (the strength) of the OFL
inquiry.
To conclude, an OFL looks to the future and
improves the organization, whereas an IBL favours
organizational change inertia and does not eliminate
the condition of risk. The improvement of organiza-
tions should not be delegated to criminal law but other
mechanisms of self-improvement must be found. This is
a topic which merits further research.
Notes
1. The latent factors are elements of organizational nature
generated from managerial decisions that can remain
silent and not easily visible in an organizational system
until an error or a violation combined with it generates
the accident.
2. If the goal is to assign the blame, as in the individual blame
logic, the reconstruction of the causal chain often stops
when someone or something is identified as being
suitable for the blame.
3. Russel (1918) suggested the elimination of the concept of
‘cause’ from the vocabulary because even advanced
natural science, for example physics, has acknowledged
that there is no such thing as an ultimate cause.
4. With the word ‘vicious circle’, a degenerative process is
meant, which beyond the will of the single subjects leads
the organization to dysfunction and inconveniences (Cro-
zier, 1963).
5. The analysis in this approach adopts a singularist cause
perspective (Anscombe, 1971) and thus is not determi-
nistic. While a deterministic perspective reduces the
causality to regular successions (X is followed by Y),
the singularist perspective assumes that only a probabil-
istic link exists between the individual events that are
causally connected. In other words, the singularist theory
of the causes supports a probabilistic point of view of the
causality, affirming that cause A does not determine the
effect B, but it increases the probability; cfr. Dekker
(2005).
6. A near miss is an event that could have caused an
accident, but for some barrier did not result in a real
accident. The difference between near miss and an
accident is in the consequences and not in the morphol-
ogy that could be in common.
7. But what are the boundaries of this analysis? If the latent
organizational factors are searched for, when should the
search stop? The way out is pragmatic: in the analysis of
an accident the generative mechanisms and hidden critical
factors are searched for (organizational and organiza-
tional field) which if removed, increase the resiliency of
the system.
8. The term veto player refers to the individual and collec-
tive decision makers whose agreement is necessary for a
change of the status quo (Tsebelis, 2002). In an organiza-
tional system, the greater the number of veto players, the
more difficult it is to change the status quo.
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The impact of crises on organizations and individuals has been stronger than ever (Wang, 2008). Thus, contemporary organizations operate in an age of extreme uncertainties and crises, such as natural calamities, global pandemics, wars, migration, infrastructure breakdowns, product and service failures, violent attacks, social unrest, and many other unpredictable conditions that made our world more vulnerable than ever. In this sense, crises include a surprise, a threat to high-priority purposes, and a limited amount of time available for preparing in advance or for responding to them after they erupt (Choi & Kim, 1999; Eismann et al., 2021). Pearson and Clair (1998) offered one of the first comprehensive definitions of an organizational crisis:Coombs (2015, p. 2) described crisis slightly differently, as a “perception of an unpredictable event” that threatens stakeholder expectations and influences organization’s performance. A more dynamic definition of a crisis was suggested by Taneja et al. (2014):Finally, MacNeil and Topping (2007) defined a crisis as an event that “causes severe emotional and social distress, which may occur at any time and without warning” (p. 64).
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Untoward injuries are unacceptably common in medical treatment, at times with tragic consequences for patients. The phrases 'an epidemic of error' and 'the medical toll' have been coined to describe this problem of 'iatrogenic harm', which it has been suggested may have contributed to 98,000 deaths per year in the US. Some of these incidents are the result of negligence on the part of doctors, but more usually they are no more than inevitable concomitants of the complexity of modern healthcare. This book is fundamentally about distinguishing the former from the latter. Although medicine is used as the book's primary example, the points made apply equally to aviation, industrial activities, and many other fields of human endeavour. The book advocates a more informed alternative to the blaming culture which has increasingly come to dominate our response to accidents, whether in the medical field or elsewhere.
Book
First published in 1985, Mary Douglas intended Risk and Acceptability as a review of the existing literature on the state of risk theory. Unsatisfied with the current studies of risk, which she found to be flawed by individualistic and psychologistic biases, she instead uses the book to argue risk analysis from an anthropological perspective. Douglas raises questions about rational choice, the provision of public good and the autonomy of the individual.
Book
Risk Perception and Decision-making The Management of Risk Disasters as Systems Failures Methodology Generation of Hindsight General Organisational Learning Specific Organisational Learning Case Studies Discussion and Conclusions