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  • 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