Just Culture, Presented by Professor Sidney Dekker
Video embedded from YouTube on 16 August 2012
Implementation of a just culture provides the cultivation of mutual trust and confidentiality; whereby individuals are encouraged, or even rewarded, for executing safe acts or for submitting necessary information regarding safety. Organisations seeking to establish or maintain a just culture must realise that weaknesses need to be exposed and examined if systems are to be effective in enhancing safety (Frankel, Leonard & Denham, 2006). At the same time, individuals who execute deliberate unsafe acts will face punitive consequences and disciplinary actions. Individuals must also aware of the difference between executing satisfactory safety acts and unsatisfactory hazardous, acts as well as the means of enacting the acceptable behaviours in operations.
Efforts to Uphold a Just Culture:
1) Official documentation of policies of a just culture are recorded.
2) Official agreements on the acceptable ideologies of satisfactory safe actions and unacceptable unsafe actions
3) Punitive actions guidelines are instilled for unsatisfactory operational conduct. However, the cancellation of one’s official qualification to handle certain operations (e.g. license) or the undertaking of further training should not be presented as a form of punishment. Instead, the cancellation of one’s license should be due to the necessity for him/her to perform according to the acceptable standards.
4) Ambiguous controversial issues are properly handled.
5) The practice of policies of a just culture is widely conveyed throughout an organisation.
6) Installation of reporting systems (anonymous systems to encourage the sharing of errors committed by the reporters themselves or by third parties)
7) All treatments are unbiased and fair.
8) Status of safety policy breaches are closely taken note of and followed up on.
9) Corresponding corrective actions are implemented.
Human Factors Benefits:
To Learn from & Avoid Mistakes
The industry is able to understand flaws and mistakes through safety investigation before subsequently implementing the relevant actions towards the preventing similar flaws and mistakes from occurring again. To err is human. It is therefore important that we forgive, be reminded of and learn from the mistakes committed.
The reporting of even minor occurrences may prove beneficial to the organisation. Often frontline workers do not perceive events to be overly significant however individual events when collated together may reveal deeper flaws in a system and therefore permit the organisation the ability to make changes.
European Organisation For The Safety of Air Navigation. (2006, March 31). Establishment of ‘just culture’ principles in atm safety data reporting and assessment. Retrieved 28 August 2010, from http://www.skybrary.aero/bookshelf/books/235.pdf.
European Organisation For The Safety of Air Navigation. (2008, February 20). Just culture. Retrieved 28 August 2010, from http://www.eurocontrol.int/esp/public/standard_page/just_culture.html.
Flight Safety Digest. (2005, March). A roadmap to a just culture: Enhancing the safety environment. Retrieved 28 August 2010, from http://www.skybrary.aero/bookshelf/books/233.pdf.
Frankel, A.S., Leonard, M.W. & Denham, C.R. (2006). Fair and Just Culture, Team Behavior, and Leadership Engagement: The Tools to Achieve High Reliability. Health Services Research, 41(4 part 2), 1690-1709. Retrieved 11 August 2011, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955339/.
LUNDS UNIVERSITET Sidney Dekker on Just Culture. Retrieved from Youtube on 16 August 2012.