The Hidden Truth Behind Industrial Incidents: Understanding Our Shared Accountability

Industrial incidents often leave a trail of blame, with scapegoats quickly identified and held responsible. Yet, when we look deeper using Latent Cause Analysis, a different story emerges. It reveals that the incident was not the fault of a single person or team but the result of many factors and decisions made by all involved. People were trying their best with the knowledge they had, operating in a situation others knew about and had previously navigated without incident. This time, however, the situation escalated beyond control.

Understanding this shared accountability is crucial for preventing future incidents and fostering a culture built on trust and continuous improvement.

Industrial control room with machinery and monitoring systems

Industrial control room with machinery and monitoring systems

What Latent Cause Analysis Reveals About Industrial Incidents

Latent Cause Analysis digs beneath the surface of an incident to uncover hidden factors that contributed to the event. Unlike immediate causes, which are often obvious errors or failures, latent causes are systemic issues embedded in processes, culture, or design. They are a reflection of the way we are.

For example, a valve failure might be a contributing cause of a leak, but the latent causes reveal:

• Inadequate maintenance schedules are the norm for the way they do business.

• Learning by doing or trial by fire is a prevalent theme in employee training

• Known design flaws are lived with and worked around rather than being fixed

• Pressure to meet production targets leads to shortcutting safety concerns

  
  

These latent causes often involve multiple departments and levels of an organization, showing that responsibility is shared. Until people realize their contribution to the problems, they will never change. The opposite is also true: when someone recognizes they are part of the problem, they will immediately change. The bottom line is you must have a process that helps people see their part in why things go wrong.

Why Scapegoating Fails to Address the Real Problem

Assigning blame to individuals or small groups after an incident provides a simple explanation and a target for punishment. However, this approach misses the complexity of industrial systems and the interconnected decisions that lead to failure.

Scapegoating can:

• Create fear and reduce openness about mistakes

• Prevent learning from the incident

• Ignore systemic weaknesses that remain unaddressed

• Lead to repeated incidents with similar causes

  
  

Instead of focusing on blame, organizations should focus on understanding how everyone’s actions and decisions contributed to the outcome, i.e., LEARN from events.

How We All Play a Part in Industrial Safety

Every person in an industrial environment influences safety, whether directly or indirectly. Operators, engineers, managers, and even external contractors contribute to the system’s overall risk profile.

Consider these examples:

• Operators following procedures but unaware of outdated instructions

• Engineers designing systems with incomplete information

• Managers prioritizing deadlines over thorough safety checks

• Contractors working under pressure (real or perceived) to meet production goals at all costs

  
  

Each of these roles involves decisions made with the best intentions, but sometimes based on incomplete knowledge or conflicting priorities.

Learning from Past Incidents That Were “Known Risks”

Many industrial incidents happen in situations that were known risks but had not caused problems before. This creates a false sense of security, leading to complacency.

For instance, a plant might have operated for years with a known equipment flaw that never caused a failure. When the flaw finally leads to an incident, it exposes the latent risk that everyone had accepted as normal.

This pattern shows the importance of:

• Understanding latency and the need to learn and improve

• Encouraging not just reporting of near misses and minor issues, but learning from them

• Challenging assumptions that do not align with the organization's core values

  
  

Building a Culture of Shared Accountability

Creating a culture where everyone understands their role starts with leadership but requires participation at all levels. When people feel responsible and supported, they are more likely to speak up and contribute to safer operations.

To move beyond blame and toward shared accountability, organizations can:

• Train their people to recognize latency

• Use Latent Cause Analysis aid in learning from things that go wrong

• Involve stakeholders, diverse teams, in reviewing incidents

• Develop action plans that address both immediate and underlying causes

• Monitor the effectiveness of changes and adjust as needed

  
  

These steps help transform incidents into learning opportunities that improve safety and productivity for everyone. It's not a one-time fix but an ongoing process. Continuous improvement means regularly learning, regularly changing/adapting by revisiting procedures, equipment, and culture to reflect new information and challenges.

Final Thoughts on Shared Accountability in Industrial Safety

Industrial incidents are never the fault of a single person or decision. The only exception would be criminal intent. Incidents result from a complex web of factors involving many people trying their best with the knowledge and resources available. Recognizing our shared accountability allows organizations to move beyond blame and focus on real solutions.

By embracing Latent Cause Analysis, fostering open communication, and committing to continuous improvement, we can build safer workplaces where incidents are less likely to happen and everyone feels responsible for the organization's success.

The next time an incident occurs, ask not who to blame but what we can learn together to prevent it from happening again. This mindset is the key to lasting safety and success.