THE JUST AND FAIR CULTURE:
THE BASIS FOR A
SOUND SAFETY CULTURE
Factors contributing to incident causation
conflicting objectives
loose culture
unclear priorities
Corporate
Governance
inadequate control of business processes
condone non-compliance
unclear expectations
inadequate HEMP process
inadequate design
Immediate causes
at sharp end
no intervention
focus on slips, trips & falls (TRCF)
lack of resources
workload
poor audits and reviews
maintenance back-log
Inadequate monitoring & corrective action
unclear roles & responsibilities
human error
not open for ‘bad’ news
focus on cost reduction
inadequate standards & procedures
Organisation &
systems
uncontrolled change management
lack of consequent management
focus on commercial targets
scorecard driven
inadequate ER system
lack of competence
Pushing operating window
production pressure
lack of supervision
poor communication and hand-over
equipment failure
acceptance of high risks
non-compliance
lack of hazard awareness
time pressure
Incident
Human errors and violations
Human
Behavior
Unintended
action
Intended
action
Violation
Mistake
Lapse
Slip
“I jumped
the light”
“I took the
wrong turn”
“I forgot
to
indicate”
“I used the
windscreen
wiper”
Not An Error
Basic Error Types
Boeing 757/767 Start Sequence
Altimeters
The perceptual discrimination difficulty makes errors
more likely (10,000 foot errors)
A Mistake
W
E
The need for rules
Many hazards cannot be controlled by hardware or
design
Other hazards are more easily controlled by
administrative approaches
There 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 purpose
Personnel are expected to know them and are
clearly expected to comply with all relevant
procedures
Failures to comply represent a deliberate failure
of an individual’s performance contract
Such failures cannot be tolerated, because the
SMS relies upon compliance
Non-compliance is best managed by making
people aware of the personal consequences, from
written warnings to dismissal
Review of the Simple View
There 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 2
Empirical studies of non-compliance showed a
complex picture
6 different types of violation
Managers and supervisors have a role as well as the
violating worker
Individuals will be working with a variety of
intentions, from the company’s interest to their
personal gain
Solutions 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
Immediate Causes - Error Types
0%
10%
20%
30%
40%
50%
Slip
Lapse
Mistake
EP
DS
Non-Compliance
Circumstances
Technical (Non-Human factor)
Environment (non-human factor)
EP = Upstream DS = Downstream
13
Underlying causes of accidents
Underlying causes - Error types
0%
10%
20%
30%
40%
50%
60%
Slip
Lapse
Mistake
EP
DS
Non-compliance
Cultural
Technical (Non-Human factor)
Environment (non-human factor)
EP = Upstream DS = Downstream
14
Violation type Description
Management
Workforce Supervision
Discipline
Coaching
A Just and Fair Culture version 3
Did they follow
all procedures
and
best practices?
Did they think
they were following
the procedures
and practices?
Normal
Compliance
Unintentional
violation
Awareness/
Understanding
Everyone does
It this way round
here.
Don’t you know?
We can’t follow
the procedure and
get the job done
I thought it was
better for the
Company to do
the job that way
I thought it was
better for me
personally to
cut a corner
Routine
violation
Situational
violation
Optimizing
violation
Personal
optimizing
violation
Screw you.
I meant to do it
my way
Reckless
personal
optimization
Oh dear
Did we do that!?
Exceptiona
l violation
Feel comfortable,
But be aware, this
May be unusual
Why didn’t people
realise this was a
Problem?
Take active steps
to identify this
sort of violation
Use MRB
Get very active.
How were poor
procedures
signed off?
Set standards.
Examine procedures
This may be a real
improvement
Set standards
Examine hiring &
retention
policies
Praise the worker
Investigate and
apply MRB
Investigate and
apply MRB
Investigate.
Must listen to
workforce
complaints
Why is this not
being recognised?
Use MRB
Allow variances
Set standards
Recognise that
Such people are
In workforce
How did we let
him stay here?
Didn’t we know
In advance?
Did we train
people in how to
react in unusual
circumstances?
Feel satisfied
Report if they
discover they have
violated a
procedure
Get involved in
finding out if the
procedure is
necessary
Must report all
such impossible
situations
Report possibility,
Raise before work
Acquire competence
Decide whether
You wish to
work here
Leave Company
Did I check with
supervisor and
colleagues?
None
No blame for
worker
Active coaching of
all, at all levels for
condoning routine
violation
Blame everyone
for not playing
their part
Blame everyone
for not playing
their part
Warning letter
to worker
Summary
dismissal
Did they follow
all procedures
and
best practices?
Praise the worker
Use as an example
For others
Management need
to examine the
quality of
procedure system
Everyone use MRB
to see if rule
necessary, or
ensure compliance
Coach people to
tell (workers)
and
listen (managers &
supervisors)
Coach people to
tell (workers)
and
listen (managers &
supervisors)
Coach managers
and supervisors
on setting
standards
Coach managers
& supervisors
to recognise &
deal with such
individuals
Did they follow
all procedures
and
best practices?
How did we hire
Such a person?
Did we not expect
such situations
to arise?
HSE-MS problem?
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 factor
The old model appears to assume individual guilt unless
proven otherwise
The drawing, (from left to right), implies visually where
priorities lie. The amount of space devoted to discipline does
the same
Application 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-compliance
It 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 causes
It 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
ERRORS
Was there a
behaviour
below
expectation?
yes
Was
something
done not the
way
originally
intended to
no
do it or was
a procedural
step
forgotten?
yes
Slip or Lapse
ORGANIZATIONAL ISSUES
Did the
person make
an incorrect
decision or
was their
work plan
no
inadequate?
yes
Mistake
Has this happened before?
Routine Error
Routine Error
Personal history of errors
Same errors by different people
Did the
person
violate a rule
or procedure
because they
were
no
unaware of
the rule or
did not
understand
it?
yes
Unintentional violation
Did the
person
violate a rule
or procedure
because they
believed the
job couldn’t
be done if
they followed
the
procedures?
yes
Situational
Violation
no
Did they
violate a rule
or procedure
thinking it
was better
for the
no
company to
do it that
way? Or,
were they
trying to
please their
boss?
yes
Organizationa
l
optimizing
violation
Do other people behave in the same way?
Routine Violation
Others do it like that
PERSONAL ISSUES
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
?
yes
Personal
optimizing
violation
yes
Reckless
Violation
Does this person have a
history of personal
violations?
Routine Violation
Personal history of violation
Sheep and Wolves
The North Sea study found 2 dimensions
Sheep’s clothing - Wolves’ clothing
Your ‘clothing’ shows if you have violated recently
Sheep - Wolves
Sheep don’t like to violate, wolves don’t mind
Sheep are the Guardians of High Standards
Wolves are go-getting opportunists
Wolves are Natural Born Violators
Why are Violations so Dangerous?
Violators assume everyone else is following the
rules and procedures
Violations are forbidden, so violators don’t tell
anyone what they are doing
Violations take the system out to the Edge
Violations destroy a main assumption of the SMS
Errors (slips, lapses, mistakes) are independent of
intention
Violation + Error = Death/Doom/Disaster
Why do People violate?
Behaviours are caused by intentions turned into
plans of action
Behaviours are a response to the recognition of an
opportunity
Poor planning makes violation a solution to a
problem
If 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 work
Supervise by watching harder over people
Punish 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
The Lethal Cocktail
The Main Predictors
Expectation
Expectation that rules will have to be bent to
get the work done
Powerfulness
The feeling that one has the ability and
experience to do the job without slavishly
following the procedures
Opportunities
Seeing opportunities that present
themselves for short cuts or to do things
‘better’
Planning
Delft
University of
Technology
Challenge the future
Inadequate work planning and advance
preparation, leading to working ‘on the fly’
and solving problems as they arise
Six Key Characteristics of a ’Highly Reliable’ Safety Cultu
Mindful
Informed
Flexible,
Learning
risk management
and continuous improvement happen here
Reporting
Just
The HSSE Culture Ladder & SMS
GENERATIVE (High Reliability Orgs)
HSE is how we do business
round here
Permanent
PROACTIVE
Safety leadership and values drive
continuous improvement
Effective
CALCULATIVE
We have systems in place to
manage all hazards
In Operation
REACTIVE
Safety is important, we do a lot
every time we have an accident
In Place
PATHOLOGICAL
Who cares as long as
we're not caught
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
31
ISMS
ISMS
ISMS
Reporting culture and rates
Aantal gemelde incidenten door ATC fouten
50
45
40
Aantal
35
30
25
20
15
10
5
0
2000
Session 27
2001
2002
Jaar
Building World Class
2003
2004