Just Culture making it work

Job Brüggen

Questions

• What IS a Just Culture?• Who needs a Just Culture?• Why do WE need a Just Culture?• Who is busy with a Just Culture?• How to make and guard a Just Culture?• Is there a law on Just Culture?• What can WE do for Just Culture?

What is a Just Culture?

• A culture in which frontline operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.“

Who needs a Just Culture?

• They are humans• Humans make mistakes• If we want these people to perform these jobs…• …we must find a way of dealing fairly and justly

with these inevitable errors.

Linear model of failure

Why do we need a Just Culture?

•Where FEAR is leading, people will not learn to improve, but people will learn not to get caught.•Learning is safer than punishing!

Pro-active learning : ROLES

Managers• Installing trust•Risk Awareness•Design for safety• Facilitate the right

choice • Effective learning

from events

Workforce• Earning Trust•Risk awareness•Design for safety •Reporting• Learning•Being a role model

Just Culture background material• Sidney Dekker. Just Culture. Balancing Safety and Accountability. Amazon

• Hearts and Minds available at the Energy Institute

• GAIN [Global Aviation Information network] A Roadmap to a Just Culture. Enhancing the Safety Environment.

• Baines & Simmons. FAiR® System (Flowchart Analysis of Investigation Results)

• Reason. Managing Risks of Organizational Accidents.Amazon.

• Reason. Human error: models and management.

• Hudson. A new model for a Just and Fair Culture.

• Hudson. Safety Culture – Theory and Practice

• Eurocontrol Skybrary - Link to Just Culture material

• Eurocontrol. Establishment of Just Culture principles in ATM safety data reporting and assessment.

• Mateou. Flying in the Face of Criminalization. The Safety Implications of Prosecuting Aviation Professionals for Accidents

• David Marx. Whack a mole. The price we pay for expecting perfection.

• Eurocontrol. Just Culture Guidance Material for Interfacing with the Judicial System

• European Commission: EU REG 2003/42

• European Commission: update

• ICAO Safety Of Information Protection TaskForce

• Eurocontrol Just Culture Policy

How to create a Just Culture?• Policy

• What you want to achieve: a learning culture.• Better one lesson learned, then ten people punished.

• Definitions :• What is good behaviour• What is bad behaviour• What you will do with BOTH

• Procedures• Define WHO gets to say what is right and wrong• Involve the workforce!

• Show good leadership• Lead by example: it is NOT only about the workforce

Tools to help classify behavior• Flavors:

1. Crude2. Old3. Complex4. Useful

David Marx-Just Culture Community

David Marx-Just Culture Community

Baines & Simmons

Baines and Simmons

Hearts and Minds

Hearts and Minds

ICAO

Eurocontrol Just Culture Task Force

Just Culture Model Policy

Coordination Just Culture and related activities:• In Europe with EU, EASA, ECAC• In ICAO and global regions

Model for a National Aviation Prosecution Policy• To be discussed and implemented at National or

Regional level

Support to the Judiciary:• Dedicated experts course for assisting Judiciary• European initiatives for establishing a dialogue

between safety and judicial experts

Netherlands’ law

• Implemented EU Directive on Aviation Reporting• Includes protection for reporters• Restrictions for prosecutor• Willful misconduct and gross negligence excluded!

Now, what can WE do?

• We shall start with OURSELVES

Safetyrights

Justicerights beliefsbeliefs

service service

A good INTERNAL Just Culture assists a good EXTERNAL Just Culture

Internal Just Culture first• Give people trust so they action their good intentions

over and above their emotions.• Better safety performance• Your Just Culture adopts already parts of the classical

beliefs of criminal justice.• Justice officers will better trust your system

Easy cases are … well, easy.

• …but where is the real line between honest mistake and culpable behavior?

SEAT RECLINE SWITCH

UP

DOWN

WINGSFALL OFF

WINGSSTAY ON

STOP

Honest mistake Reckless behavior

Interpreting human behavior• “The line” is drawn in 256

shades of gray!• INTENT is what counts,

not the outcome

• Reward and stimulate positive behavior

• What about the (non-)actions of the manager?

www.safetyandjustice.eu

• Sharing practical experience handling (internal) Just Culture issues• Multiple fields• Healthcare• Processindustry• Aviation

• Interactive• Smartphone-ready (Just Culture in your pocket!)• Expansions to Inspection, Prosecutor roles (future)

The background• Based on JC “models” and theory• James Reason• David Marx• Baines & Simmons• Hearts & Minds• Sidney Dekker

• Synthesis • Avoid too simplistic views• Take out overcomplicated theories• Emphasize the positive side• Include the management

Navigator

The websitewww.safetyandjustice.eu

Just Culture in your Pocket

firstaid.safetyandjustice.eu

Now what is your status?

A. Fallen asleep

B. Stayed awake but did not understand

C. Yeah interesting, thanks

D. I am going to do something with it.