1NSR/Safety en NSI/Kwaliteit & Veiligheid

Just Culture in action?

Operationalization of the‘Just Culture concept’ at Dutch Railways

Merlijn Mikkers, Safety Advisor Dutch RailwaysFrank Guldenmund, Delft University of Technology

2NSR/Safety en NSI/Kwaliteit & Veiligheid

Topics

• Safety culture and Just culture

• How to operationalize the just culture concept?: the just culture guideline

• Experiences

• Conclusion

• Discussion

3NSR/Safety en NSI/Kwaliteit & Veiligheid

Safety culture subject in investigations after major disasters since mid eighties

Chernobyl, 1986

BP Texas, 2005Challenger,

1986

Piper Alpha, 1988

The concept of Safety culture

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If this openness is not part and parcel of the safety culture, there is the risk of:

• Limited information flow

• Top management less aware of what is happening in organisation

• Disturbed relation between (first-line) employees and management

Openness and honest disclosure amongst employees in an organisation is an important precondition for (organisational) learning

(Bloomfield, 2003)

Openness is a precondition for a mature safety culture

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Justness towards employees part of safety culture

Just culture part of both organisational and safety culture

Safety culture

Organi-sational culture

Just Culture

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Organisational triangle

structure

culture processes

Be-haviour

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Processes

Structure Culture

Synergy between organisational elements

structure

culture processes

Be-haviour

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Processes

Structure

Synergy between organisational elements

structure

culture processes

Be-haviour

Culture

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Culture

Processes

Synergy between organisational elements

structure

culture processes

Be-haviour

Structure

• To create a just culture, a holistic approach is necessary

• Organising the process and anchor this in a structure helps to promote ajust culture

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• Starting point is that every incident (for example SPADs) needs to be contemplated

with all contextual factors

• Individual actions are always discussed with reference to the total system in which

they were taken

• The guideline does not provide a dividing line between ‘acceptable’ and not

‘acceptable behaviour’ (or a human error classification scheme)

• Instead, it describes the process that needs to be followed

when an incident happens

Just culture guideline at Dutch Railways

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• Decision process about the future employability and whether certain actions need

to be taken for future employability and what research questions need to be

answered in the incident investigation

• In that way, the guideline is linked to the incident investigation procedure of the

safety management system of Dutch Railways (anchoring in a structure)

• The role of consolation (by the team manager of the involved employee) and the

manager that participates in the committee are strictly separated

Just culture guideline at Dutch Railways

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The guideline is structured in three ‘responsibilities’:

Just culture guideline at Dutch Railways

Investigation:

Safety department

Advise:

Advisory committee

Decision making:

Management

Information (based on interview)

Research questions

Advise about future employability

• Committee members: safety expert, peer of the involved employee (for example a

train driver in case of a SPAD), human resources officer and manager

• So, ‘different perspectives’ are represented in the advisory committee

• Balancing thoroughness of the advice needs to be balanced with the fact that the

employee involved is uncertain about whether or when (s)he can perform his or her

job again

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Just culture guideline at Dutch Railways

A key question that the committee has to answer is the so-called substitution question:

Would a different person have made the same mistake under the same circumstances?

• This question is answered in relation to the complex contextual and individual factors that

have played a role

• If (targeted) individual actions seem necessary, this will be done to improve safety and to

help the employee to improve his or her performance

• Punish employees will only be done in cases of malfunction (for example alcohol

consumption during service)

A tool / document with background information and tips is developedto stimulate discussion in the committee

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Experiences with using the guideline

• It is important to balance the aim of the Just Culture guideline

with the description of practical and juridical implications

• Use the guideline as a ‘guide’line, not as ‘regulation’

• Involving a ‘peer’ in the committee is experienced (also by management) as significant

added value

• Employees that participate in the committee need to be trained, this is part of the

implementation process

• The results of a questionnaire show that the guideline is experienced as positive and

helps to shift the focus

• from the individual component to system components and

• from punishing individuals to actions that improve the system

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Conclusions

• The approach of organising the process and anchor this in a structure, instead of

beforehand drawing a line between ‘acceptable’ and ‘not acceptable’ behaviour seems

successful

• Including a peer in the advisory committee is experienced as very positive

• There are some clues that indicate that it helps to create more openness

• Development and implementation of a ‘Just Culture guideline’ should be a collaborative

process, with management, safety staff, work’s council, and so on

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Discussion / Questions