THE JUST AND FAIR CULTURE:THE BASIS FOR A

SOUND SAFETY CULTURE

Factors contributing to incident causation

Corporate Governance

loose cultureconflicting objectives

unclear expectations

unclear priorities

focus on commercial targets

uncontrolled change management

inadequate control of business processes

condone non-compliance

lack of consequent management

scorecard driven

not open for ‘bad’ news

focus on slips, trips & falls (TRCF)focus on cost reduction

Immediate causes at sharp end

human error

equipment failureno intervention

Incidentlack of hazard awarenessacceptance of high risks

poor communication and hand-over

non-compliance

Organisation & systems

inadequate standards & procedures

lack of competence

lack of resources poor audits and reviews

inadequate design

maintenance back-log

time pressure

workloadinadequate HEMP process

Inadequate monitoring & corrective action

lack of supervisionunclear roles & responsibilities inadequate ER system production pressure

Pushing operating window

Human Behavior

Unintended action

Intended action

SlipViolation LapseMistake

“I forgot to

indicate”

“I used the windscreen

wiper”

“I took the wrong turn”

Basic Error Types

“I jumped the light”

Human errors and violations

Not An Error

Boeing 757/767 Start Sequence

Altimeters

The perceptual discrimination difficulty makes errors more likely (10,000 foot errors)

W

E

A Mistake

The need for rules

Many hazards cannot be controlled by hardware or designOther hazards are more easily controlled by administrative approachesThere are three levels of specification

Guidelines – “Ought to”Descriptions and sequences – “Should”Work instructions – “Must”

Failure to follow procedures temporarily negates the control of the management system

The assumption is that all the rules will be followed

The Simple (Old) View -How to manage non-compliance

Rules and procedures are there for a purposePersonnel are expected to know them and are clearly expected to comply with all relevant proceduresFailures to comply represent a deliberate failure of an individual’s performance contractSuch failures cannot be tolerated, because the SMS relies upon complianceNon-compliance is best managed by making people aware of the personal consequences, from written warnings to dismissal

Review of the Simple ViewThere is an assumption that all rules and procedures are optimal and not in need of improvement

The US Nuclear INPO studies found that 60% of procedural problems were due to incorrect procedures

The requirement is for unquestioning compliance by a worker

The INPO studies found that most people did follow procedures, even when they were incorrect

A weaker version of such requirements may require challenge

This is often based upon following the incorrect rule or procedure first, with subsequent challenge

ISMS

The Just Culture - Version 2Empirical studies of non-compliance showed a complex picture6 different types of violationManagers and supervisors have a role as well as the violating workerIndividuals will be working with a variety of intentions, from the company’s interest to their personal gainSolutions range from improving the system to ensuring compliance

Types of Violation

• Unintended• Knowledge and understanding• Avaliability

• Situational• Optimizing

• Personal benefit• Organizational benefit

• Exceptional

• Routine is a multiplier on the different types (excluding exceptional)

Individual causes of accidents

13

Immediate Causes - Error Types

0% 10% 20% 30% 40% 50%

Slip

Lapse

Mistake

Non-Compliance

Circumstances

Technical (Non-Human factor)

Environment (non-human factor)

EPDS

EP = Upstream DS = Downstream

Underlying causes of accidents

14

Underlying causes - Error types

0% 10% 20% 30% 40% 50% 60%

Slip

Lapse

Mistake

Non-compliance

Cultural

Technical (Non-Human factor)

Environment (non-human factor)

EPDS

EP = Upstream DS = Downstream

A Just and Fair Culture version 3Did they followall procedures

andbest practices?

Did they thinkthey were following

the proceduresand practices?

Everyone doesIt this way round

here.Don’t you know?

We can’t 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 dearDid we do that!?

Normal Compliance

Routine violation

Situational violation

Optimizing violation

Personal optimizing violation

Reckless personal

optimization

Exceptional violation

Unintentional violation

Awareness/ Understanding

Man

agem

ent

Supe

rvis

ion

Des

crip

tion

Wor

kfor

ceD

isci

plin

eCo

achi

ngVi

olat

ion

type

Feel comfortable,But be aware, thisMay be unusual

Did we not expectsuch situations

to arise?HSE-MS problem?

Set standards.Examine proceduresThis may be a real

improvement

How did we hireSuch a person?

Set standardsExamine hiring &

retentionpolicies

Why didn’t peoplerealise this was a

Problem?

Take active stepsto identify this sort of violation

Use MRB

Get very active.How were poor

proceduressigned off?

Praise the worker

Did we trainpeople in how toreact in unusual circumstances?

Why is this notbeing recognised?

Use MRBAllow variances

How did we let him stay here?Didn’t we know

In advance?

Set standardsRecognise that

Such people areIn workforce

Investigate and apply MRB

Investigate and apply MRB

Investigate. Must listen to

workforcecomplaints

Feel satisfiedDid I check withsupervisor and

colleagues?

Report possibility,Raise before work

Acquire competenceLeave Company

Decide whetherYou wish towork here

Report if theydiscover they have

violated aprocedure

Get involved infinding out if the

procedure isnecessary

Must report allsuch impossible

situations

None

Did they followall procedures

andbest practices?

Blame everyonefor not playing

their part

Summarydismissal

Warning letterto worker

No blame forworker

Active coaching ofall, at all levels forcondoning routine

violation

Blame everyonefor not playing

their part

Praise the workerUse as an example

For others

Did they followall procedures

andbest practices?

Coach people totell (workers)

andlisten (managers &

supervisors)

Coach managers& supervisors

to recognise &deal with such

individuals

Coach managersand supervisors

on settingstandards

Management needto examine the

quality of procedure system

Everyone use MRBto see if rulenecessary, or

ensure compliance

Coach people totell (workers)

andlisten (managers &

supervisors)

Why Replace “Just Culture”with another model?

Application can drive undesirable behaviour e.g A fatality investigation highlighted previous use of “Just Culture” as a contributory factorThe old model appears to assume individual guilt unless proven otherwiseThe drawing, (from left to right), implies visually where priorities lie. The amount of space devoted to discipline does the sameApplication of framework is not seen as ‘Just’ – often called “7 ways to sack yourself”The old model focuses mostly on the person at the “sharp end” and does not take into account the role of the manager/supervisor in creating the environment which led to the action

ISMS

Why is the new model better?

This is a just and fair model because it recognises safety behaviour as well as non-complianceIt recognises that managers and supervisors have a role as well as the violating worker.The model looks at everyone's role in the incident.

It builds on the psychology of understanding different types of violation and their causesIt recognises that individuals will be working with a variety of intentions, from the company’s interest to their personal gain

Meets visual requirements for priorities

Accountability

• The model helps define accountabilities, and consequences for success and failure at all levels

• Workforce individuals have specific roles only they can play

• Supervisors play a vital role between top and bottom

• Managers have responsibilities, identifiable in terms of accountabilities, that everyone else relies on

Conclusion

• It is possible to identify what people should do• This needs to be placed in a clear and public process• Success creates two of the pillars of an advanced

culture of safety• Trust• Accountability

Human Error and Violation Decision Flowchart

Was there a behaviour

below expectation?

Was something

done not the way

originally intended to do it or was a procedural

step forgotten?

Did the person make an incorrect decision or

was their work plan

inadequate?

Did the person

violate a rule or procedure because they

were unaware of the rule or

did not understand

it?

Did the person

violate a rule or procedure because they believed the job couldn’t

be done if they followed

the procedures?

Did they violate a rule or procedure

thinking it was better

for the company to

do it that way? Or,

were they trying to

please their boss?

Did the person

violating think it was

better for them

personally to do it that

way?

Did the person violating mean

to do what they did and did not think

or care about the

consequences?

ERRORS ORGANIZATIONAL ISSUES PERSONAL ISSUES

Slip or Lapse Mistake Unintentional violation

SituationalViolation

Organizational

optimizingviolation

Personaloptimizingviolation

RecklessViolation

Has this happened before?

Routine Error

Personal history of errors

Routine Error

Same errors by different people

Routine Violation

Others do it like that

Routine Violation

Personal history of violation

Do other people behave in the same way? Does this person have a history of personal

violations?

yes yes yes yes yes yes

yes no

yes

no no no no

Sheep and Wolves

The North Sea study found 2 dimensionsSheep’s clothing - Wolves’ clothing

Your ‘clothing’ shows if you have violated recently Sheep - Wolves

Sheep don’t like to violate, wolves don’t mindSheep are the Guardians of High StandardsWolves are go-getting opportunistsWolves are Natural Born Violators

Why are Violations so Dangerous?Violators assume everyone else is following the rules and proceduresViolations are forbidden, so violators don’t tell anyone what they are doingViolations take the system out to the EdgeViolations destroy a main assumption of the SMSErrors (slips, lapses, mistakes) are independent of intentionViolation + Error = Death/Doom/Disaster

Why do People violate?Behaviours are caused by intentions turned into plans of actionBehaviours are a response to the recognition of an opportunityPoor planning makes violation a solution to a problemIf nothing has improved since last time, people will expect to violate again

An Alternative Model:Supervision and Punishment

An alternative model, what many managers think will workSupervise by watching harder over peoplePunish whenever people are caught

Behavioural Cause model explained 64.2%Supervise and Punish explained 20%Combining both models explained 67.0%Added value from 64.2% to 67.0%

Attribution errors, judgment and honesty

• The fundamental attribution error• Different in cultures individualism – collectivism• Different for pilots and surgeons

• Hindsight bias – knew it all along

• The just world and punishment• Bad things happen to bad people

Challenge the future

DelftUniversity ofTechnology

The Lethal CocktailThe Main Predictors

Powerfulness

Opportunities

Planning

Expectation Expectation that rules will have to be bent to get the work done

The feeling that one has the ability and experience to do the job without slavishly

following the procedures

Seeing opportunities that present themselves for short cuts or to do things

‘better’

Inadequate work planning and advance preparation, leading to working ‘on the fly’

and solving problems as they arise

Mindful

Informed

Reporting

Just

Flexible,Learning

risk managementand continuous improvement happen here

Six Key Characteristics of a ’Highly Reliable’ Safety Cultu

The HSSE Culture Ladder & SMS

CALCULATIVEWe have systems in place to

manage all hazards

PROACTIVESafety leadership and values drive

continuous improvement

REACTIVESafety is important, we do a lotevery time we have an accident

PATHOLOGICALWho cares as long as

we're not caught

GENERATIVE (High Reliability Orgs)HSE is how we do business

round here

In Place

In Operation

Effective

Permanent

Notre approche de la culture de sécurité des vols

Just & Fair

Implementation lessons learned

• Get everyone on board first• Unions, managers, senior managers• The managers have to agree to be put in the firing line

• Involve Human Resources from the start• They consider training and real consequences to be their

territory• Agree a process of evaluation

• Start quarterly joint evaluations with all parties• Reduce frequency with success and acceptance to annually

• The negative side is much easier than the positive

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ISMS

ISMS

ISMS

Reporting culture and rates

Session 27 Building World Class

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