Accountability? Just another word for blame?

- english gareth lock incidents just culture Oct 16, 2022

 What does accountability mean to you? In many cases, it is finding someone who is liable for a specific action, to ensure that a task is satisfactorily done, someone to point the finger at and say “Why did this just happen? Fix it”. However, is accountability what we really want if we want to learn and improve? We already know from many experiences and from research, that punishment does not facilitate learning and change. Rather it often leads to people working to avoid having their errant behaviours detected because they fear being caught or punished, not that they have changed their behaviour because they want to.

Accountability can take two different approaches:

  • You can have backwards-looking accountability, where you are looking to find someone or an organisation to hold to account, to ‘pay the account’ for the damages encountered, and to ultimately be responsible for what happened, even if it was a ‘genuine human error’.
  • You can also have forward-looking accountability, where you work with those involved (those harmed, and those involved in the harm-giving) to each tell their account, to explain how they feel and how they are hurt, and what needs to be done to resolve that hurt and harm. Restorative ‘just culture’ is based around forward-looking accountability and asks three questions: who was hurt, what do they need, and whose obligation is it to address those needs?

Shouldn’t we be looking at responsibility when it comes to making improvements rather than accountability? Accountability is the liability to ensure the task is done properly, responsibility is the obligation to successfully perform a task. Responsibility and accountability are often used as synonyms, but responsibility is about doing, whereas accountability is about reporting. Would you rather have someone involved in doing something to address safety concerns, or someone providing an account? Accounts are massively important, especially when we get multiple perspectives about the same event, and so we can the different stories of those involved and the context they were immersed in. At the same time, we need to create change, and that means doing something. You can make someone accountable, but you have to take responsibility.

Anger at Work: How Negative Emotions Cloud Judgment - Knowledge at Wharton

When something goes wrong, our judgements are clouded by cognitive biases and emotions. The more severe the outcome, the harsher we judge the situation. The closer we are to those involved, those that are hurt, the more powerful the emotions we feel. It is completely normal to feel anger and frustration that you can’t do anything, you can’t bring that loved one back. Someone SHOULD have done something to prevent that critical event from happening, and they need to do something to stop it from happening again.

What those involved in serious injuries and fatalities most often really want is an apology, to understand what happened, and to know that something is being done to prevent the same thing from happening to someone else.


Learning from Healthcare

In healthcare (especially in the US), there are changes to attitudes from a defensive and protectionist approach to one where the hospitals work with and communicate with the families and survivors to help them understand what happened, to apologise, and to provide financial assistance, all without going through the legal system under a litigious approach. These Communications and Resolutions Programmes have been successful in terms of improving organisational learning, improving patient safety, and reducing litigation costs. This happens because those involved in healthcare operations can now explain the gaps between ‘Work as Imagined’ and “Work as Done, and the tensions, shortcuts and issues that are always present when work is done. Their effectiveness is based on the deployment of human factors and Just Culture programmes which focus on understanding of both the variability of human performance (errors are normal) and also the error-producing conditions which exist in the system. The Merseyside NHS Trust has also made massive inroads into deploying a Just Culture programme across their whole Trust to improve learning and patient safety. 

The problem is there is a perception that this is a no-blame culture. Far from it. Getting those involved to talk about what happened is not easy, especially when it comes to speaking directly with the families of those hurt or killed. There is often genuine remorse about what happened – if only the conversations can happen. 

In diving, fortunately, we don’t have many issues of serious harm or death, but we do have many near-misses, ‘human errors’, or issues that lead to things going wrong. There should be reflection, and there should be an understanding of how it made sense for all parties to do what they did. If we think back to the Restorative Just Culture approach: 

  • Who was hurt? This isn’t just the first ‘victim’, normally a diver, but could also be an instructor, the dive centre, or the training agency, or those involved in the rescue, recovery or medical care of those physically hurt. These are known as second and third victims
  • What do they need? An apology? It isn’t also just medical assistance, it could also be psychological support, reputation management, additional training (or changes to the system), additional resources, better understanding of human performance, higher standards, better quality control...they are all event specific, and can only be found by having an open and candid conversation which explores the conflicts and trade-offs within the system.
  • Whose obligation is it to address this? Herein lies the million-dollar question! Depending on what is involved, this could be a multitude of different parties.

You can see an example of this change in attitude following a post about a cavern dive with a father and son. The social media, unfortunately, tore into the father for not recognising the issue, and interviews with him showed that he didn't 'get it' and was unsafe. And yet, there were some people who realised that he needed advice, guidance and training, delivered in a compassionate manner, not to pour fuel onto the fire of defensiveness.

So what?

So the next time you think you want to hold someone accountable for something going wrong with the goal of helping to learn and improve, consider whether are you looking to blame someone or are you looking to hear an account, many accounts, to help understand the local rationality of those involved and their second stories? When we start to hear the context-rich stories, the second stories, about the constant trade-offs and tensions that exist, we have a much better understanding of the event and we start to realise that people were trying to do the best they could with the resources they had at the time. We also have a better idea of whose obligation or responsibility it is to address the issues at hand.

Gareth Lock is the owner of The Human Diver, a niche company focused on educating and developing divers, instructors and related teams to be high-performing. If you'd like to deepen your diving experience, consider taking the online introduction course which will change your attitude towards diving because safety is your perception, visit the website