Download - Just Culture: More important than a Safety Culture? · 2017-03-29 · • ‘Just Culture’ means a culture in which front-line operators or other persons are not punished for actions,

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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



experience tells us…

Human behaviour and

performance are cited as

causal factors in the

majority of incidents.


4



The case for a Just CultureTransformation

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 AerospaceRolls-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


Elements of Just Culture

Company policy

Fair treatmentReporting 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 Culture9

Company policy

Fair treatmentReporting 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


Just Culture Beliefs and DutiesOrganisation

Recognise that

people

make mistakes

We will treat

people fairly

Recognising that

People develop

unhealthy ‘norms’

Errors

Will be reported

Product Safety

will improveNot tolerate

reckless conduct

Committed to develop,

support and resource

staff


Just Culture Beliefs and DutiesThe Individual

Raise hand if you

make a mistake

Participate

in learning

Avoid reckless

behaviour

Minimise

at-risk behaviourReport risks &

suggestions

for Improvements

Stop the job

and fix


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 CultureCompany

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


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


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


Event Review Group

Intended ActionUnintended Consequence

Unintended Action Unintended Consequence

Intended ActionIntended Consequence

May include consoling, coaching or training

Manage through taking appropriate disciplinary action

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

‘th

e lin

e in

th

e sa

nd

’

Error Rule Breaking for Personal Gain

Mistake

Recklessness

SabotageSituation / Routine Rule Breaking

ExceptionalRule 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


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 principled decision making process

• Not jumping to a blame conclusion but to remain curious and

open-minded through the investigation

» Policy - Document and Communicate

» Standards - Set and Agree

» Implementation - Voluntary Reporting System

» Monitor - Go Look See and get Feedback


Summary

• Establish Just Culture beliefs and duties

• Embody them in your daily work

• Don’t expect others to follow the beliefs and duties if you don’t

• You won’t have a healthy Safety Culture if you don’t have a Just Culture

Where is your “line in the sand” and does it make you a

safer organisation?
