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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