Safety investigations designed to find 'systemic' failures almost always end up blaming individuals because humans are easier for bureaucracies to process than complex structures.
We assume modern root-cause analyses are objective searches for truth, but this research shows a 'responsibility convergence' where organizations consistently settle on human error as the cause. This happens because individuals are 'administratively legible' anchors that allow a case to be closed, whereas fixing a distributed sociotechnical system is seen as unactionable.
Responsibility Convergence in Organizational Investigations: Structural Dynamics of Blame in Root Cause Analysis
SSRN · 6372301
Organizational investigations such as root cause analysis (RCA) are intended to identify systemic causes of failure and support organizational learning. Yet across regulated and safety-critical environments, investigative conclusions recurrently stabilize responsibility at identifiable individuals despite formal commitments to system-oriented explanation. This persistent actor-centered pattern presents a theoretical puzzle: why do investigative systems designed to diffuse responsibility across s