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

Baines Simmons Limited 2009

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

Baines Simmons Limited 2009

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

Baines Simmons Limited 2009

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

Baines Simmons Limited 2009

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 circumsta