OT Safety Bulletin

Just Culture

There is a lot written about just culture and it is certainly worth some further reading as the subject covers some important and widely challenging issues.

Professor James Reason describes a ‘just’ culture as “an atmosphere of trust in which people are encouraged (even rewarded for providing essential safety related information), but in which they are also clear about where the line must be drawn between acceptable and an unacceptable behaviour”.

In Professor Reason’s view, a safety culture depends critically upon first negotiating where the line should be drawn between unacceptable behaviour and blameless unsafe acts. There will always be a grey area between these two extremes where the issue has to be decided on a case by case basis.  He further states that the general indications are that only around 10 percent of actions contributing to bad events are judged as culpable.

A number of organisations employ James Reason’s culpability model, or a variation on this to aid them in assessing the acceptable behaviour. It is a flowchart based on a series of questions that assists in assessing a degree of culpability following an investigation. In addition to this there are other aspects to consider which may be explored using a substitution and/ or routine test. An important point is then who conducts these?

Professor Dekker notes that a ‘just’ culture is meant to balance learning from incidents with accountability for their consequences.  His advice to creating the basis for a Just Culture is that firstly incidents need to be normalised and legitimised. Incidents should be seen not as failures or shameful, but a learning opportunity to improve an organisation.

To do this he suggests firstly abolishing penalties, implement a debriefing process after any incidents to support and develop the normalisation of incidents. Have an independent safety department. Educate all staff on the importance of reporting to enable learning and understand that incidents are not shameful but sources of good information. Convince all that the difference between an unsafe and safe organisation is not how many incidents it has, but how it deals with them. People should know their rights and duties following an incident, who to and not to talk to.

People then need to know who gets to draw the line with acceptable and unacceptable behaviour. Dekker notes that this line is a judgement not a location. The organisation needs to arrange and make people aware of who handles the incident follow up, and how peer expertise is integrated into the follow up. Next the organisation needs to carefully consider how it will protect its data from undue outside probing.

Lastly, it is worth discussing with the prosecuting authority how they can be supported in making better judgements in pursuing any investigations and prosecutions.

Within a ‘just’ culture David Marx outlines 3 reactions to incidents: console the human error, coach the at-risk behaviours and look to punish the reckless behaviour.

It is important for all to understand basic human factors as it assists greatly in examining all of this. Professor Dekker asks that instead of looking at human error and the human being the issue, instead think that the human actually is the important component that has the adaptability and resilience to ensure the imperfect systems and processes work most of the time.

In any organisation all this needs to be understood from the top to the bottom with the full backing from those at the top. Without this it is never going to work.

So the next time there is an incident in your organisation think about how it is subsequently handled and how people within your organisation view it.