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Building a Just Culture for Safety
Performance
- Can it work across national cultures?
Keven Baines – Director
25th March 2015
CHC Safety & Quality Summit
© 2015 Baines Simmons Limited
Workshop flow
2
3. How to build one?
4. Does it deliver/work across national cultures?
2. What is it?
1. Just Culture – why?
Just Culture for safety performance
© 2015 Baines Simmons Limited
Just Culture – why?
A proactive safety culture that is founded upon a Just Culture
Being Just is the bedrock of safety performance
Encourages openness and proactive reporting of hazards
Enables you to discover what people have to do to get the job done
Facilitates risk-based decision-making
3 Just Culture for safety performance
© 2015 Baines Simmons Limited
How did Just Culture evolve?
Blame and Train
Culture
No Blame Culture
Just Culture
Just Culture for safety performance 4
© 2015 Baines Simmons Limited
Just Culture the key Safety Performance enabler
A Proactive Culture is the
bedrock of safety performance.
A Proactive Safety Culture
encompasses an organisation’s
commonly held perceptions and
beliefs regarding safety and has the
potential to significantly influence
people’s behaviour.
A Proactive Safety Culture is
founded upon a Just Culture in
which individuals freely and openly
share safety-related information in
an atmosphere of trust, born from
a sense of justice.
Just Culture for safety performance
© 2015 Baines Simmons Limited
What are the benefits of Just Culture?
Information
Risks
Improved (risk-based) decision-making
Just Culture
Reporting
Confidence in being treated fairly and feeling
able to change something
Just Culture for safety performance
© 2015 Baines Simmons Limited
Regulatory context
New European regulation on mandatory occurrence reporting
(No.376/2104) in force from November 2015
“Each organisation established in a Member State shall
.. adopt internal rules describing how ‘just culture’ principles ... are guaranteed and implemented within that organisation.”
7 Just Culture for safety performance
© 2015 Baines Simmons Limited
Definition of Just Culture
A culture that recognises that competent
professionals make errors and acknowledges
that even competent professionals will develop
unhealthy norms (shortcuts, routine rule
violations), but has zero tolerance for reckless
behaviour
Just Culture for safety performance
© 2015 Baines Simmons Limited
0%
100%
Human
Reliability
Performance Influencing Factors (PIFs)
The Human Reliability Curve
Human
Error
Normal
Operation
The ‘Error Zone’
It’s part of the human condition to err
9 Just Culture for safety performance
© 2015 Baines Simmons Limited
Types of error
Because I didn’t quite do what I wanted to do: error (slip)
Because I forgot or wasn’t concentrating: error (lapse)
Because I made the ‘wrong’ decision or plan: mistake
10 Just Culture for safety performance
© 2015 Baines Simmons Limited
Why are rules intentionally broken?
Because there is no other choice to get the job done: situational violation
Because this situation has never been imagined: exceptional violation
Because it’s what we do here: violation for organisational gain
Cant, don't, won’t
11 Just Culture for safety performance
© 2015 Baines Simmons Limited
Error or violation?
Just Culture for safety performance
© 2015 Baines Simmons Limited
Error or violation?
39 times...
Just Culture for safety performance
© 2015 Baines Simmons Limited
Error or violation?
Just Culture for safety performance
© 2015 Baines Simmons Limited
Do YOU role model it?
Can YOU find it? Can YOU explain it?
Do YOU follow the
process?
“Thanks, but we already have a Just Culture”
Just
Culture
Defined
Understood
Applied Demonstrated
Just Culture for safety performance
© 2015 Baines Simmons Limited
Just Culture Self assessment
16
Client’s average score 43%
Just Culture for safety performance
© 2015 Baines Simmons Limited
It can be measured?
17
Just Culture for safety performance
© 2015 Baines Simmons Limited
Company 1 - safety culture diagnostic
Just Culture for safety performance
© 2015 Baines Simmons Limited
Company 2 - safety culture diagnostic
Just Culture for safety performance
© 2015 Baines Simmons Limited
The safety performance indicators for Just culture
Just Culture for safety performance
© 2015 Baines Simmons Limited
Workshop flow
21
3. How to build one?
4. Does it deliver/work across national cultures?
2. What is it?
1. Just Culture – why?
Just Culture for safety performance
© 2015 Baines Simmons Limited
Just Culture – How?
Understand Build Power-up Perform
Just culture assessment
Safety culture diagnostic
Where are we
now?
What do
we need
to put in
place?
Safety vision
Policies
Procedures
Investigation process
Just Culture toolkit
How do
we
energise
our
staff?
Competence devt
Coaching
Promotion
Education
How do we
sustain our
culture? How
do we know it
is working?
Assurance
Metrics
Balanced scorecard
Safety culture diagnostic...
Just Culture for safety performance
© 2015 Baines Simmons Limited
Just Culture Vision
By the end of 2016 we will have:
...opened up the culture through a high degree of trust between staff and all levels of management
...everyone able to describe our Just Culture and it will positively shape their decision making
...become increasingly (20% year on year) less occurrence and more hazard centric
...become increasingly 3rd age so that we know what our people have to do to get the job done
...a culture were unjustified risk taking behaviour will not be tolerated at any level
...everyone with a genuine ability to say “stop” and be supported by us
...with no exception (irrespective of outcome severity) our Just Culture process will always be applied.
23 Just Culture for safety performance
© 2015 Baines Simmons Limited
Error Management System
Threats
and or CFs
Reactive
Unsafe Act (Error/Mistake/Violation)
Event (Unwanted Harm)
Occurrence Reporting
Feedback & Promotion to Develop a
Learning Safety Culture
Hazard/Near-Miss/Error/Mistake/Violation Reporting
Pro Active
Data Exploitation to make human-in-the-
system risk based decisions
Interventions
Investigations
Just Culture toolkit - inc. Event Review Group
and or PIFs
Hazards
Just Culture for safety performance
© 2015 Baines Simmons Limited
FAiR® - what is it..?
a ‘behaviour-based system for creating and sustaining a Just Culture’
… to enable an organisation to ensure that interventions consider the ‘Human In The System’ (HITS)
...treating all in a fair and importantly - a consistent manner
Identify effective interventions
Ensure personal accountability is balanced with the desire for learning and improvement
Focus on actions and intentions rather than consequences
Cross cultural commonality
Just Culture for safety performance
© 2015 Baines Simmons Limited
26 Just Culture for safety performance
© 2015 Baines Simmons Limited
Event Review Group responsibilities
27
To ensure a Human Factors-centric investigation and report is complete
identifying the root cause
contributing factors
Ensuring all the ‘Why did it happen?’ questions have been answered
To ensure effective interventions are put in place following an event
To determine any potential acc
