From: Carmen Nitsche <carmen.nitsche**At_Symbol_Here**PISTOIAALLIANCE.ORG>
Subject: Re: [DCHAS-L] Rush To Judgment
Date: Wed, 22 Aug 2018 10:21:24 -0400
Reply-To: ACS Division of Chemical Health and Safety <DCHAS-L**At_Symbol_Here**PRINCETON.EDU>
Message-ID: 397F7A49-FFC9-4A6F-BA6C-877E8B3CB52C**At_Symbol_Here**

Thanks for posting this Ralph. The rush to judgement and the blame game is a huge barrier to improving safety culture. 

This challenge is one reason we decided in the Pistoia Alliance Chemical Safety Library ( to drain the emotion/judgement from the equation. We only collect the relevant chemical data of a reaction incident (e.g. compound name, InChI, Reaction class, functional group, scale of reaction, description of unexpected outcome, suggestions for avoidance).  And we anonymize submitting person/company. 

Nonetheless we find some potential submitters worry about blame/shame/judgement and chose not to share their valuable insights. 

This is unfortunate. We need to be helping one another avoid incidents and create an environment that allows each of us to share our story to achieve improved safety outcomes. 

Thanks again for making all of us aware of this post.  Safe travels home. =E2=80"Carmen 

Carmen Nitsche
Business Development
Pistoia Alliance

On Aug 22, 2018, at 6:28 AM, Ralph Stuart <000005bc294e9212-dmarc-request**At_Symbol_Here**LISTS..PRINCETON.EDU> wrote:

This new blog post addresses the issue I raised in my presentation yesterday relative the challenge presented in developing "Lessons Learned" from safety incidents. Organizational investigation practices often lead to simplistic conclusions about complex situations... I've excerpted the opening paragraphs from the complete article.

- Ralph


In our rush to judgment we rarely intend to do harm. Often, we react to incomplete or even scant information, fit it into our own mental model of how things should be and then jump to conclusions that could inflict harm.

Last week, CBS Morning News showed a film clip of a man snagging a baseball from a kid who was sitting directly in front of him. The less than 10 second clip resulted in the vilification of the man as a bully who stole the ball from the little kid. One day later the same news show provided an apology to the man for jumping to judgment. Why the change? Simply put, the news media learned the context around the actions and found that the man had caught and given away several balls to those around him including the boy in front of him.

Context is something that helps us to walk in the shoes of others - but it takes time and effort to learn context. Often it is much easier to live in a land of blame and shame. Our organizational responses to incidents and accidents have followed the same path and resulted in investigation reports that name individuals as the cause of accidents without a mechanism that helps the investigator to learn or discover context.

Our tendency is to oversimplify - enter the concept of requisite variety, which implies that the complexity of our assessment of systems has to meet the complexity of the systems that we are scrutinizing. Yet, so many of our processes are not designed to embrace complex systems.


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