The Chris Argyris memorial column #23: How to blame less and learn more

“Accountability. We hear a lot about it. It’s a buzzword. Politicians should be accountable for their actions; social workers for the children they are supervising; nurses for their patients. But there’s a catastrophic problem with our concept of accountability.Consider the case of Peter Connelly, better known as Baby P, a child who died at the hands of his mother, her boyfriend and her boyfriend’s brother in 2007. The perpetrators were sentenced to prison. But the media focused its outrage on a different group: mainly his social worker, Maria Ward, and Sharon Shoesmith, director of children’s services. The local council offices were surrounded by a crowd holding placards. In interviews, protesters and politicians demanded their sacking. “They must be held accountable,” it was said.

“Many were convinced that the social work profession would improve its performance in the aftermath of the furore. This is what people think accountability looks like: a muscular response to failure. It is about forcing people to sit up and take responsibility. As one pundit put it: “It will focus minds.”

“Should they have been penalised? Or censured? The industry commissioned an investigator to probe deeper. He found that the two switches were identical and side by side. Under the pressure of a difficult landing, pilots were pressing the wrong switch. It was an error trap, an indication that human error often emerges from deeper systemic factors. The industry responded not by sacking the pilots but by attaching a rubber wheel to the landing-gear switch and a small flap shape to the flaps control. The buttons now had an intuitive meaning, easily identified under pressure. Accidents of this kind disappeared overnight.

This is sometimes called forward accountability: the responsibility to learn lessons so that future people are not harmed by avoidable mistakes.”

via How to blame less and learn more | Matthew Syed | Comment is free | The Guardian.

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