“What if we had…” Learning from Counterfactual Thinking

Have you ever had a close call or a near-miss and started the what-if process? Perhaps you thought to yourself something like, “If only we had done something different, the situation could have turned out much worse.” This is known as counterfactual thinking, where we consider an alternate outcome based on different antecedents. Essentially we think about changing the causal factors in the past to arrive at a different outcome. This may be done in two ways; when we think about how things could have ended up worse or when we think about changing the causal factors to end up with a better outcome. In reality counterfactual thinking applies to the past so there is really no way to create an alternate outcome (at least not until time travel is invented). However, counterfactual thinking could be applied to situations to think about actions in future scenarios. I think this process comes somewhat naturally to many people, but the way it is used may be ineffective (blaming individuals) or more effectively to improve the organization. Here are some examples:

1. The post-accident counterfactual that blames the employee. You’ve probably heard of this one. An employee experiences an injury or a team experiences a failure and investigators immediately start looking for the scapegoat(s) to tell them, “If only you had followed the procedures this accident wouldn’t have happened” or “If only you had paid more attention you wouldn’t have made this mistake.” These types of approaches fail to take into consideration the context of the situation and how events may have unfolded to place the worker or team in a position to take the actions they took. This is the sort of deficient retrospective understanding that claims to know everything because the outcome is already known, yet it does little to explain how something happened.

2. The post-accident counterfactual that is used for learning. This is similar to the approach above in that it is used after an accident or failure to analyze the causal events and to consider what could be changed in the future to attempt to avoid the same situation. This can be useful for learning if applied properly, but in some cases, it can still be problematic. For example, if a worker is injured and the team does a quick investigation and rather than blaming the employee determines a root cause, and corrects that root cause they may have reduced the likelihood that the exact same accident will occur as a result of the exact same cause, but if they ignore additional causal factors the same outcome could still occur, but from different causes than the “root case” that was rectified.

3. The post-incident/near-miss counterfactual that never takes place, but should have. In some ways maybe this is the worst situation of the three. How many times do organizations what-if potential outcomes after minor injuries, yet when near-misses occur that could have potentially had serious consequences, the team members wipe the sweat off their brows, exclaim,  “We got lucky on that one,” and then go about their business as if nothing happened? In many cases organizations get so focused on production they may miss opportunities for learning if they fail to consider counterfactual thinking in near-miss situations. I remember years ago in my Marine Corps aviation career experiencing numerous near-misses and while it seemed intuitive to conduct counterfactual thinking, like “If only this or that had happened instead we might not be here right now,” but for many years there wasn’t an easy way to capture and share this information. Now there are methods in place to record this type of information, including anonymous online reporting systems. Sometimes near-misses offer great opportunities for improving if the organization chooses to learn from them. That requires management and leadership to set the tone, demonstrate their willingness to learn, and lead from the front.

There are other examples and uses for counterfactuals, but I think the important point is to use counterfactual thinking like a tool in a toolkit. Not every tool will get the job done, but in complicated and complex work, a good toolkit with multiple tools will likely provide the resources needed to achieve success and to improve performance along the way. If counterfactual thinking is usedin a positive way to learn from the past and to think about future outcomes, but in a way that doesn’t seek to lay blame and that considers the system and context of work it may be a useful tool. One of the points I make in my Crew Resource Management training is that we can never be perfect, but we can learn and improve.