Just Culture: More important than a Safety Culture? · PDF file 2017-03-29 ·...

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Transcript of Just Culture: More important than a Safety Culture? · PDF file 2017-03-29 ·...

  • Trusted to deliver excellence

    © 2017 Rolls-Royce plc

    The information in this document is the property of Rolls-Royce plc and may not be copied or communicated to a third party, or used for any purpose other

    than that for which it is supplied without the express written consent of Rolls-Royce plc.

    This information is given in good faith based upon the latest information available to Rolls-Royce plc, no warranty or representation is given concerning

    such information, which must not be taken as establishing any contractual or other commitment binding upon Rolls-Royce plc or any of its subsidiary or

    associated companies.

    Rolls-Royce proprietary information

    Just Culture: More important than a

    Safety Culture?

    Where is your “line in the sand” ………..

    Steve Burrill Head of Engineering - Customer Services Centre

  • What is Just Culture?

    Elements of a Just Culture?

    Content

    The case for a Just Culture

    Summary

    Rolls-Royce proprietary information

  • The case for a Just Culture

    experience tells us…

    Human behaviour and

    performance are cited as

    causal factors in the

    majority of incidents.

    Rolls-Royce proprietary information

  • 4

    The case for a Just Culture

    Rolls-Royce proprietary information

  • The case for a Just Culture Transformation

    5

    Just Culture is a key

    enabler for an

    engaged and healthy

    Safety Culture

    Reporting

    Just

    Learning

    Flexible

    Questioning

    This applies to every thing we do

    including Safety, quality etc.

    Group Culture

    Safety Culture

    Just Culture

    Just Culture is now a law for European Civil Aerospace Rolls-Royce proprietary information

    Adopted from James Reason, “Managing Risks of Organizational Accidents”

  • What is a Just Culture ?

    Just Culture Definition:

    An atmosphere of trust exists in which people are:

    • Encouraged, and even rewarded, for providing essential safety-related

    information.

    • Protected from inappropriate judgement and discipline when an event occurs

    due to making inadvertent mistakes or making best endeavours to meet

    organisational goals with or without appropriate organisational support.

    • People are also clear about where the line must be drawn between

    acceptable and unacceptable behaviour.

    EC regulation 376/2014(12)

    • ‘Just Culture’ means a culture in which front-line operators or other persons

    are not punished for actions, omissions or decisions taken by them that are

    commensurate with their experience and training, but in which gross

    negligence, wilful violations and destructive acts are not tolerated;

    6

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  • Rolls-Royce proprietary information

  • Elements of Just Culture

    Company policy

    Fair treatment Reporting and investigation

    TRUST

    C

    B

    An environment of trust exists within the organisation and its leadership

    actively demonstrate their commitments to the Just Culture principles

    A

  • Elements of Just Culture 9

    Company policy

    Fair treatment Reporting and investigation

    TRUST

    Company principles for Just Culture documented,

    and recognised by employee representatives

    Commitment of company / staff and managers

    Communications / publicity / training

    Continuous effective implementation &

    improvement

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  • Rolls-Royce proprietary information

  • Just Culture Beliefs and Duties Organisation

    Recognise that

    people

    make mistakes

    We will treat

    people fairly

    Recognising that

    People develop

    unhealthy ‘norms’

    Errors

    Will be reported

    Product Safety

    will improve Not tolerate

    reckless conduct

    Committed to develop,

    support and resource

    staff

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  • Just Culture Beliefs and Duties The Individual

    Raise hand if you

    make a mistake

    Participate

    in learning

    Avoid reckless

    behaviour

    Minimise

    at-risk behaviour Report risks &

    suggestions

    for Improvements

    Stop the job

    and fix

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  • Elements of a Just Culture

    Company policy

    Fair treatment

    Reporting and

    investigation

    TRUST

    Acknowledges the limits of human performance

    Applying fair treatment is part of what we do

    (training and support is available), people are

    protected

    Assume positive intent

    Actions focused on system performance and

    contributing factors first before consideration of

    disciplinary actions for reckless behaviours

    Assessments to determine appropriate actions

    are transparent, standards, communicated

    Active support to individuals involved in external

    investigation / proceedings

  • Elements of Just Culture Company

    policy

    Fair treatment

    Reporting and

    investigation

    TRUST

    Basic reporting and investigations support Just:

    • Reporters understand their duty to report, are

    confident to report & receive feedback when

    they do

    • Reporting is encouraged, embraced,

    publicised (good spots) and rewarded

    • Reporting is easy and accessible

    • Appropriate handling of the reports:

    • for investigation purpose only

    • safeguard confidentiality

    • safeguard identities

    • Investigations process and tools consider

    human factors (e.g. culpability assessment)

    and lead to effective corrective actions

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  • Behaviours Flowchart

    START - Investigation report

    prepared

    Under the circumstances were all applicable rules

    available, workable, intelligible and

    correct?

    Was there a conscious AND substantial AND

    unjustifiable disregard for risk?

    Were the rules intentionally

    broken?

    Was a correct plan of action selected?

    Were the actions at the time to benefit the individual only?

    Was the situation at the time outside of normal practice?

    Were the consequence as

    intended?

    No

    No

    ERROR

    MISTAKE

    No

    No

    SITUATION / ROUTINE RULE BREAKING

    No

    Yes

    Yes

    Yes

    Yes RULE BREAKING FOR PERSONAL GAIN

    RECKLESSNESS

    SABOTAGE

    No

    Yes

    Yes

    EXCEPTIONAL RULE BREAKING

    RULE BREAKING FOR ORGANISATIONAL

    GAIN

    No

    Yes

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  • Just Culture - Recognises we are Human

    Human Error – Inadvertent

    Action: Console and Learn

    Risky Behaviour – e.g. routine rule breaking

    Action: Coach

    Reckless Behaviour –

    Conscious disregard for safety

    Action: Punish

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  • Event Review Group

    Intended Action Unintended Consequence

    Unintended Action Unintended Consequence

    Intended Action Intended Consequence

    May include consoling, coaching or training

    Manage through taking appropriate disciplinary action

    May include coaching, training and/or taking minor administrative action

    ‘t h

    e lin

    e in

    t h

    e sa

    n d

    Error Rule Breaking for Personal Gain

    Mistake

    Recklessness

    SabotageSituation / Routine Rule Breaking

    Exceptional Rule Breaking

    Rule Breaking for Organisation Gain

    Substitution Test: Would your peers with the same competence behave in the same way in the same circumstances?

    Routine Test: Has this event happened before to either the individual or within the organisation?

    Proportionality Test: What safety value will punishment have?

    Increasing Culpability

    Recommendations: What needs to happen to reduce the likelihood of recurrence in the context of the person, task, situation and environment.

    Did Behaviours Cross the Line?

    e.g. misinterpreting

    information on a gauge or

    paperwork

    eg missing out minor steps you

    think are unnecessary, due to

    time pressure

    eg deliberately missing out a

    critical task to get home early

    HUMAN ERROR RISKY BEHAVIOUR RECKLESS BEHAVIOUR

    May include consoling, coaching or training

    Manage through taking appropriate disciplinary action

    May include coaching, training and/or taking minor administrative action

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  • Judgement Messages

    • We can easily jump to conclusions based on consequence

    • The more we understand about the circumstances, the more we

    tend to be lenient

    • This is why we need a princ