Later, on our way to the car, someone asked if we knew what was going on? Apparently, all the lifts had been closed.

I checked the news several times over the next few days trying to figure out what happened. Then Wednesday’s News&Guide carried a story on the incident. Apparently, a man performing routine maintenance on the tram towers was hit by the arm of a tram car and sustained serious injuries. His name and details about his condition were not reported.

What struck me was the way the people who spoke to the reporter about the accident emphasized that the injured man had been in an “unauthorized area.” No doubt he was, but for some reason repeating this information felt like an attempt to shift blame for the incident onto the victim. He was in the wrong place, so it’s his fault. All the other parties involved — including Jackson Hole Mountain Resort, the subcontractor, the injured man’s work partner and the tram crew — seem to be absolved of any responsibility for the situation with this tactic.

But the man was not working in a vacuum. Presumably he had been trained and was considered capable of performing the job. Presumably his employer — Tower Painters — followed basic safety protocols to protect him and his fellow workers. Presumably there was no malicious intent or gross negligence involved. Still, something happened. For some reason the injured man ended up in the wrong place at the wrong time.

It’s easy to blame him, but that seems too easy, and it shifts responsibility and accountability away from the people and organizations that oversaw his work, and who, I believe, bear ultimate responsibility for job-site safety.

Early in my career with the National Outdoor Leadership School, a student on a winter course was killed in an avalanche. Richard Sarnoff was 41. He was midway across a slope with his group when the slide released. Three people were caught but only Richard was fully buried. He died from suffocation.

NOLS’ response to the accident was, in my mind, incredible, partly because of the Sarnoff family’s desire to learn from Richard’s death.

NOLS could have blamed the instructors and washed its hands of the episode. After all, the instructors led the students into harm’s way. But instead the administration chose to look at the accident in terms of systems. Countless factors led to that particular situation, on that particular day, in that particular location. Everything from training to instructor team dynamics to equipment, weather and expectations played a role in the cascade of falling dominoes that ended with the fatal avalanche.

So in its inquiry into the incident the school sought to determine where its weak points were hidden — where its systems failed. What were the critical factors leading up to the accident that NOLS as an organization could address to help minimize the risk of similar situations occurring in the future?

In the end NOLS’s winter program was almost entirely revamped. Training for winter staff was redesigned and modernized. A winter-program manager was hired to develop curriculum, keep abreast of industry standards and ensure instructors had the proper equipment, experience and support they needed to be as safe as possible leading students into the winter environment. The school became one of the leaders in the world of avalanche education and there hasn’t been another avalanche fatality.

No one in the NOLS winter program would say that the changes made to the school’s systems guarantee no one else will die on a winter course, but analyzing the accident in a systems fashion allowed the school and its staff to be better prepared to lead students safely through avalanche terrain. I doubt those same lessons would have been learned if NOLS had simply scapegoated the three instructors involved, firing them and calling it good.

“Systems thinking” like this is commonly used by businesses and in the medical field to analyze problems or situations. The goal of systems thinking is to avoid focusing on individuals and instead to examine an organization’s overall structure in an attempt to understand how a problem or situation develops in the first place.

Marilyn Paul writes on TheSystemThinker.com blog, “When errors … surface, blaming seems to be a natural reflex in many organizations. Even those individuals who wish to learn from mistakes fall into naming culprits. Once we figure out who’s at fault, then we try to find out what is wrong with the supposed offenders. Only when we discover what is wrong with them do we feel as if we have grasped the problem. Clearly, they are the problem, and changing or getting rid of them (or simply being angry at them) is the solution.”

But, she continues, “There’s a problem with this common scenario. Where there is blame, there is no learning. Where there is blame, open minds close, inquiry tends to cease and the desire to understand the whole system diminishes. When people work in an atmosphere of blame, they naturally cover up their errors and hide their real concerns. And when the energy goes into finger-pointing, scapegoating, and denying responsibility, productivity suffers because the organization lacks information about the real state of affairs.”

I believe it’s more helpful for us to recognize the role that training, personality, history and experience play in creating the conditions we face than it is to focus on one person’s decisions and behavior. It’s more educational to recognize that no situation is the result of a single poor decision or inappropriate action. Instead, when you examine accidents in detail going back in time and asking yourself “why” over and over again, you can identify interrelated events that ultimately led to the moment when everything fell apart.

Who knows what happened to the man on the tower on July 23? Who knows what factors led him to disregard protocol and enter an unauthorized zone? It could have been as simple as he was in a hurry, was tired and hungry and was looking for a shortcut. It could have been he didn’t recognize the danger. It could have been he wasn’t properly trained or hadn’t had enough breaks that day so he wasn’t thinking properly. He might have been hot. He might have felt pressure to get done quickly. Speed might translate to a bonus.

I can come up with all sorts of maybes that could have contributed to the accident. That’s not to say that people are blameless. We all make mistakes. The worker could have — and probably did — make a mistake. But if we just say we all make mistakes whenever there’s an accident or problem and leave it at that, nothing ever changes and we are likely to repeat ourselves over and over again.