The Weekly Reflektion Week 42 / 2020

Does creating a scapegoat bring the team together? This week’s Reflektion concerns the clash between a blame culture, and a learning culture.

Does getting rid of the people who make mistakes improve overall team performance?

A few years ago, I was responsible for drilling operations on an offshore production platform. During a well operation the drilling supervisor proposed an improvement to the original plan, which would save several hours rig time. This was the behaviour that I encouraged to ensure continuous improvement in the drilling operations. He outlined the plan to both me and the drilling superintendent, and we agreed to go with it. The activity was an inflow test of the production casing using base oil and a downhole packer. When reverse circulating out the base oil, focus on the pump pressure was lost, and problems with the downhole packer caused an over-pressure of the annulus, bursting the production casing.

The investigation into the incident revealed that both the drilling supervisor and toolpusher, both experienced, competent hands, with a good performance record, became distracted at a critical time, and the response to the developing situation was too slow. An open and honest process followed,and we held a workshop to determine learning points and mitigating actions going forward.

A week later my superior in the UK rang to ask me how I had reacted to the findings from the investigation into the incident. He was surprised that I had not fired all those involved as he had expected. I explained the culture we try to encourage is a learning organisation, with open and honest reporting, and firing people was not the way to achieve this. I managed to talk him round to sending warning letters to those involved. Of course, since I was also involved in the process, I had to send a warning letter to myself. In the letter I pointed out that I had not ensured that the procedures were adequate for the activity and that the procedures were carried out properly. I was also critical to me not asking the right questions and ensuring the risks were understood. The letter is probably still in my file in HR, perhaps next to the ‘One Team’ files. I am unsure as to the effect of these warning letters, but hopefully the open and honest reporting culture was maintained.

In another incident, this time on a rig not under my responsibility, a toolpusher was sent off the rig because the operator had found out a potentially serious incident had not been reported immediately. Again, in my experience, people do things with the best of intentions, based on the information they have and their mental model of what is required. In this case I asked why they thought he had not reported the incident. The reason was obvious, it was claimed, as he would have been run-off if he had reported it anyway. Strange that they thought that his reaction was unexpected. He had nothing to lose.

Finding a scapegoat to blame may make someone feel better, it absolves others of any responsibility, may unite the oneswho didn’t get blamed, and give them a feeling of relief that the matter is resolved. However, if getting rid of someone is perceived as being unfair then this could erode the trust in the management and investigation processes. People may not be so open next time and will probably be concerned about how they may be treated in any future incident. The part management play in the chain of events leading to incidents is often ignored.