The agitation of the managers sitting in the meeting room is palpable. The safety director sits stiffly at the conference table. Everyone is overwhelmed by a hurricane of thoughts. "We did everything we could, right?" Conjectures whirl. Voices surge. "We've spent the last three years installing a safety management system to keep this sort of thing from happening. It was textbook!”
These leaders wonder to themselves, “Did I do something that led to this?" But soul-searching eventually gives way to frustration as a voice stands out in the room: "What were they thinking out there?"
People grab hold of these words and their implication – that the incident occurred because a handful of people in the field did something wrong. It seems a simple matter of fact that explains what happened and points to what must be done next. "We will review our policies, retrain everyone, hold people accountable and get rid of those we can't trust." And it works … until the next storm blows in.
This scenario has played out countless times, with an array of casts and in the aftermath of many different kinds of events. Some are small-scale events, like an employee failing to lock out equipment before servicing it. Others are catastrophic events, like an exploding chemical plant.
My colleagues at The RAD Group and I propose that the thought process represented here is a trap, and one that people at all levels of an organization can fall into quite naturally. We call it the “human error trap,” and when organizations become ensnared, they find themselves unwittingly stuck in a status quo of safety.