The Accident Report said “The post hit the truck”

Posted August 7th, 2007

I just finished reading Mistakes Were Made(but not by me). The authors, Carol Tavris and Elliott Aronson, made me think about an accident report from a few years ago. I was responsible for reviewing and approving all incident analysis reports in the lessons learned system. I was also responsible for building a learning culture that accepted individual responsibility for errors and accidents.

People and organizations will not learn from mistakes until they begin accepting responsibility.  A vehicle accident report was submitted.  Because the company had a disciplinary policy for individuals, people carefully worded these reports. In this case, the driver had taken the truck onto a pipeline right of way.  The right of way had not been mowed recently, so the grass and weeds were high.  Pipelines are marked with steel marker posts, which are stuck several feet into the ground.  They do not easily move.

Because the driver could not see the marker post, his truck struck the marker post.  This caused damage to the truck.  An incident analysis was done by a local team, and a safety coordinator facilitated the analysis.  The primary cause of the damage was “struck against” an object.  But the description was “the post hit the truck.”

I had a question for the safety coordinator.  “How did the post strike the truck?,” I asked.  He explained the difficulty of getting the group to agree on what to write in the report.

“But why would they want to say the post hit the truck?,” I asked.  “Don’t you think anyone who reads the report is going to wonder how a post, stuck in the ground, hit the truck?”

He had no good answer, so I changed the report to reflect that the truck hit a marker post.  That then generated more discussions with his manager, the driver’s manager, and that manager’s manager.

All of them were caught up in a process of justifying the decision by the driver.  Their cognitive dissonance, their attempts to hold two conflicting beliefs at the same time, caused them to agree that the post hit the truck.  One belief was that all accidents are preventable, which is what the company believed.  The other belief was that, because this was an accident, the responsibility should be assigned to an object and not a person.

When challenged about how the post hit the truck, the overwhelming reaction was to attack the person who raised the question.  Certainly, the accident affected individual and team goals negatively.  The post had no goals, so it wouldn’t be affected.  It’s reasonable to blame it on the post.  It is also ridiculous.  We need to take responsibility for our actions.

This entry was posted on Tuesday, August 7th, 2007 at 10:03 am and is filed under Human Factors, Operational Excellence.