Just Culture

Baines Simmons Limited 2008

Keven Baines Managing Director Baines Simmons Limited

Just Culture from aspiration to reality

Background to this work The fragility of a Just Culture - inconsistency of Just Policy application is a

common killer of a safety culture

Our experience of the real-world application of extant culpability models taught us that there is a pressing need for a:

workable, straightforward toolset

toolset which can be repeatedly and credibly applied by non-HF specialists

toolset that does not require extensive training

tool that minimises variability, ensures consistency and stands the test of perishable training

Outcome The FAIR system (Flowchart Analysis of Investigation Results)

FAIR is free of charge


PresenterPresentation Notestool that can help apply a standard to support the promotion of a just culture within an organisation.

The basis of FAIR

The best practice elements of the two main academic (Reason/Hudson) in-use models

(C) Baines Simmons Limited 2009

No

Were the actions as intended?

Yes

SabotageMalevolent

damageetc.

Were the consequences as

intended

Yes

Pass substitution test

Pass

Deficiencies in training &

selection or inexperience

Possible error of

judgement

SystemInduced

Error

History of unsafe

acts

Blameless error but corrective training or counselling indicated

Blameless error

Yes No

Diminishingculpability

Substitution Test Question to peers: Given the circumstances,

is it possible that you could have made the same or a similar error

If answer yes then blame inappropriate. The best people can make the worst mistakes.

*Knowingly means knew operating procedures exist but ignored/chose not to comply with them.

Safe Operating procedures are: Standard practices Company policy and procedures Maintenance manual procedures

Unauthorizedsubstance? No

Yes

Medicalcondition?

Substance abuse with mitigation

Substance abuse without

mitigation

No Yes

Yes

Fail

*Knowinglyviolating

safe operating procedures

Were procedures available, workable,

intelligible and correct?

Yes

SystemInduced violation

Possiblerecklessviolation

No

Evidence of reckless, optimising or negligent behaviour

SituationalViolation -Under pressure to get job done

Routine or Normative Common practice to ignoreProcedure

Yes No

Yes

No

No

Prof. James Reason - Culpability Model Further developed by QANTAS Airlines and Baines Simmons Limited

Yes

Did they followall procedures

andbest practices?

Did they thinkthey were followingcorrect procedures

and practices?

Everyone doesIt this way around

here.Dont you?

We cant followthe procedure andget the job done

I thought it wasbetter for the

Company to dothe job that way

I thought it wasbetter for mepersonally tocut a corner

Screw you.I meant to do it

my way

Oh %$#@we did that!?

Normal Compliance Routine violation Situational violation Optimizing violation

Personal optimizing violation

Reckless personal optimization

Exceptional violation

Unintentional violation

Awareness/ Understanding

Man

agem

ent

Sup

ervi

sion

Des

crip

tion

Wor

kfor

ceD

isci

plin

eC

oach

ing

Vio

latio

n ty

pe

Feel comfortable,But be aware, thisMay be unusual

Did we not expectsuch situations

to arise?EHS-MS problem?

Examine processesThis may be a real

improvement

How did we hireSuch a person?

Set standardsExamine hiring &

retentionpolicies

Why didnt peoplerealize this was a

Problem?

Take active stepsto reduce frequency of violation or norm

Get engaged-how much is this

happening? Can I let it continue?

Praise the worker

Did we trainpeople in how toreact in unusual circumstances?

Why is this notbeing recognized?Use processes to

legitimize variances

How did we let him stay here?Didnt we know

In advance?

Set standardsrecognize that

such people areIn workforce

Investigate and apply standards

Investigate and raise awareness

ofstandards

Investigate-Must listen to

workforcecomplaints

Feel satisfiedDid I/we use ALL

resources?

Report possibility,raise before work

acquire competenceLeave Company

Decide whetheryou wish towork here

Report if theydiscover they have

violated aprocedure

Get involved inaligning procedure

to reality

Must report allsuch impossible

situations

None

Did they followall procedures

andbest practices?

First level formal discipline

counseling

Third-level discipline

e.g. dismissal

Second-levelDiscipline e.g.

warning letter or time off

Console theworker

Active coaching ofall, at all levels forcondoning routine

violation

First level formal discipline

counseling

Praise the workerUse as an example

For others

We all need to look in the mirror

Counsel people totell (workers)

andlisten (managers &

supervisors)

N/AN/A

Management needto examine the

quality of Procedures/ system

Validate standardsto see if rulenecessary, or

ensure compliance

Counsel people totell (workers)

andlisten (managers &

supervisors)

Prof. Patrick Hudson Just Culture Model

Were *safe operating procedures knowingly ignored /

rules broken?

In the circumstances of the event, could the task have been done in accordance with safe*

operating procedures?

Sabotage or reckless behaviour

Were the consequences as intended?

Was the situation outside normal operating procedures?

Situational rule-breaking

Exceptional rule-breaking

Did the actions benefit the organization?

Did the actions benefit the individual?

Personal optimising rule-

breaking

Organisational optimising rule-

breaking

Apply routine and substitution test at each outcome to determine most appropriate intervention actions

Flowchart Analysis of Investigation Results (FAIR)

Yes Yes

Y

Yes

No

No

No

Was the correct plan of action selected?

No

Mistake / unintentional rule-breaking

No

Y

Y

No


ErrorYes

Unintended Action

Unintended Consequence

Error (slips and lapses)

Skill-based

Memory or attentional failure

Unintentional rule-breaking

Mistake

Rule-based

Knowledge-based

Sabotage

Reckless behaviour

Gross negligence

Personal optimising

Knowing rule-breaking

Situational

Organisational optimising

Exceptional

1 - Substitution test: Would someone else in the same situation have done the same thing? (if not, what is it about individual?)

2 - Routine test: Does this happen often to a) the individual or b) the organisation?

4 - Intervention: What needs to happen to reduce likelihood of recurrence at a) an individual level and b) an organisational level?

Increasing culpability

3 - Proportional punishment test: What safety value will punishment have?

The

line

in th

e sa

nd

Manage through appropriatedisciplinary action

Manage through improving performance influencing factors (PIFs) person, task, situation, environment

Flowchart Analysis of Investigation Results (FAIR)

Intended Action

Unintended Consequence

Intended Action

Intended Consequence

Managing The Three Behaviours

At-Risk Behaviour

Manage through:

Understanding our at-risk behaviours

Removing incentives for at-risk behaviours

Creating incentives for healthy behaviour

Increasing situational awareness

Intentional Risk-Taking

Manage through:

Disciplinary action

Normal Error

Manage through changes in the immediate system:

Processes

Procedures

Training

Design

Environment

Move or manage the person


Carry out Root Cause Investigation (using tools such as MEDA, HFIT, PEAT, REDA) using trained investigators

Further unsafe act information required

*FAIR system

See next page Instigate

disciplinary process

Investigation Output - Event Review Team

(ERT) convened

No Further action regarding person

Non-Judgemental Decision Judgemental

Precautionary action?

Unwanted

event/error or

near miss


Where does FAIR reside in your Error Management System?

(developed) Substitution Testing

This must be carried out by the Event Review Team (ERT) on at least three of the persons peers.

The substitution test is designed to ascertain whether, in the circumstances, it is possible that another similarly skilled, trained and experienced individual would have done anything different.

These peers must not be members of the ERT, investigation or any other committee that could bring in a pre-existing knowledge or bias that would be directly associated with the event/near-miss circumstances.

If answer no then it is most likely a system problem, not necessarily an individuals problem, and blame is not appropriate. It proves that the best people can make the worst mistakes.

Ask other peers this question Could you have made the same or similar error under similar circumstances?

Peers must consider the event/near-miss contributing factors i.e. (maintenance) system failures, and circumstances beyond the individuals control as determined through the related investigation.

If the peer group indicates a positive response (yes) the person is probably blameless.

A review of their previous decision history is in order. If they have a previous history of poor decision-making, counseling may be in order depending on event/near-miss factors.


What is a Just Culture?A Set of Beliefs A recognition that professionals will make mistakes A recognition that even professionals will develop unhealthy norms A fierce intolerance for reckless conduct An expectation that hazards and errors will be reported Accountability for choosing to take risk Expectation that system safety will improve

A Set of Duties To raise your hand and say Ive made a mistake To raise your hand when you see risk To resist the growth of at-risk behaviour To participate in generating learning from our every-day bad experiences To absolutely avoid reckless conduct

Baines Simmons Limited 2009Inspiration: David Marx

Does a Just Culture deliver?

Some interesting lessons regarding the application of the Just Culture

No of MEMS Raised Cumulatively - 4 RR sites

0

100

200

300

400

500

600

Dec-04

Feb-

05

Apr-0

5

Jun-05

Aug-

05

Oct-0

5

Dec-05

Feb-

06

Apr-0

6

Jun-06

Aug-

06

Oct-0

6

Dec-06

Feb-

07

Apr-0

7

Jun-07

Aug-

07

Oct-0

7

Dec-07

Feb-

08

Apr-0

8

Jun-08

Aug-

08

Date

No

of

ME

MS

Attack Helicopter Depth Support Unit

Internal Reporting

FURBYs Raised from Nov 07

020406080

100120140160180200

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43

Weeks

FURB

Ys

FURBYs Raised

15

The MAS Programme

Senior Mgt HF Training

HF Programme

MEDA Training

Continuation Training

Safety Review Board

Safety Action Groups

SMS Training

2005 20072006 2008

Reactive Systems

Proactive Culture

MEMS Report 700 +

MEDA Investigations 200 +

Initial HF Trained 2800 +

The Error Iceberg

The Error Iceberg

PresenterPresentation Notes The journey so far. Senior Management buy in and training commenced in 2005 followed by our initial Human Factors programme. Specialist investigators were then being utilised in 2006 with Human Factors continuation training initiating in 2007. Over the last two years MAS has instigated safety management training, safety review boards and safety action groups converting a reactive Error Management System into a proactive safety culture throughout the organisation. To date over 700 open reports have been managed, over 200 Human Factor investigations carried out and over 2800 employees have completed initial Human Factor training. The journey to the bottom of the Error Iceberg continues.

Thankyou

Regeneration outcomes

0

50

100

150

200

250

2006 2007 2008

Annual Occurrence Reports Raised

PresenterPresentation NotesThe outcome of the regeneration so far reporting increasing each year

A good indicator of the health of the system

and the increased trust from employees

A more detailed breakdown for the last year can be seen on

NEXT SLIDE MONTHLY REPORTS

QANTAS Maintenance ErrorManagement System

air safe

A Journey to the Bottom of the Error Iceberg MEMS Implementation 2005 2008

17

0

1000

2000

3000

4000

5000

6000

7000

AQD Raised TechnicalOccurrences Sep 06 - Aug 07

Form 500 Raised QualityOccurrences Sep 07 - Aug 08

Medium and Above Low Risk

Low risk items including non event items/near miss

QANTAS Maintenance ErrorManagement System

air safe

A Journey to the Bottom of the Error Iceberg MEMS Implementation 2005 2008

18

Reasons for Increased Reporting

- Increased belief that Just Culture Principles will be followed

- Changing belief in reporting making a difference

- Better understanding of reporting via HF training

- No Punitive actions outside of Just Policy

- Much easier to report via online reporting system

- Good MEDA Investigations and results

Measures to protect Just Culture only one committee member to be technically

knowledgeable

only one investigator to be technically knowledgeable

only one investigator to be local

confidentiality maintained

Investigators have limited participation in decision making process

no secrets published procedure promoted from the top downwards

Measures to protect Just Culture

Train the Management Team (an example curriculum)

An Introduction to Human Error

Managing Error

Managing At-Risk Behavior

Managing Reckless Behavior

Developing a reporting culture

The Investigation Process

Just Culture and its link to safety

How to do just culture

Making Smart System Changes

The reality of being Just

As we move into the brave world of SMS, the actions that an organization takes for or against its people after an event occurs will continue to be the single biggest determiner of its success (in terms of managing safety proactively)

Its the doing that's the undoing...


Its the doing that can be the undoing

2

Summary

Being fair is a management accountability (be tough)

Managing consistency is the real challenge, or being just most of the time irrespective of output failure consequence

Formally record how you responded - for performance review by seniors and independents

The regulator should care too


Conclusion

The FAIR tool a workable, and straightforward toolset which can be repeatedly and credibly applied by non-HF specialists, without the need for extensive training

So that our people tell us about safety

Interested in trialling/using FAIR?

please leave your business card, or contact us through our website

In return we would value your feedback as to its usability

PresenterPresentation NotesAn enlightened regulator will be seeking to answer:

Identify - Did they identify the real hazards?Assess - How big were those hazards?Control - What measures did they have in place to control those hazards?Recover - What plans did they have when it still went wrong?

Slide Number 1Background to this workThe basis of FAIRSlide Number 4Slide Number 5Slide Number 6Slide Number 7Managing The Three BehavioursWhere does FAIR reside in your Error Management System?(developed) Substitution TestingWhat is a Just Culture?Does a Just Culture deliver?Slide Number 13Internal Reporting The MAS ProgrammeRegeneration outcomesSlide Number 17Slide Number 18Measures to protect Just CultureMeasures to protect Just CultureThe reality of being JustIts the doing that can be the undoingSummaryConclusion

Just Culture

Documents

Transcript of Just Culture