A just culture protects people's honest mistakes from being seen as culpable. But what is an honest mistake, or rather, when is a mistake no longer honest? It is too simple to assert that there should be consequences for those who 'cross the line'. Lines don't just exist out there, ready to be crossed or obeyed. We – people – construct those lines; and we draw them differently all the time, depending on the language we use to describe the mistake, on hindsight, history, tradition, and a host of other factors.
What matters is not where the line goes – but who gets to draw it. If we leave that to chance, or to prosecutors, or fail to tell operators honestly about who may end up drawing the line, then a just culture may be very difficult to achieve.
The absence of a just culture in an organization, in a country, in an industry, hurts both justice and safety. Responses to incidents and accidents that are seen as unjust can impede safety investigations, promote fear rather than mindfulness in people who do safety-critical work, make organizations more bureaucratic rather than more careful, and cultivate professional secrecy, evasion, and self-protection. A just culture is critical for the creation of a safety culture. Without reporting of failures and problems, without openness and information sharing, a safety culture cannot flourish.
Drawing on his experience with practitioners (in nursing, air traffic control and professional aviation) whose errors were turned into crimes, Dekker lays out a new view of just culture. This book will help you to create an environment where learning and accountability are fairly and constructively balanced.
Contents: Preface; Prologue: a nurse's error became a crime; Why bother with a just culture?; Between culpable and blameless; The importance, risk and protection of reporting; The importance, risk and protection of disclosure; Are all mistakes equal?; Hindsight and determining culpability; 'You have nothing to fear if you've done nothing wrong'; Without prosecutors there would be no crime; Are judicial proceedings bad for safety?; Stakeholders in the legal pursuit of justice; 3 questions for a just culture; Not individuals or systems, but individuals in systems; A staggered approach to building your just culture; Epilogue; Index.
About the Author: Sidney Dekker is Professor and Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University in Brisbane, Australia. Previously Professor at Lund University, Sweden, and Director of the Leonardo Da Vinci Center for Complexity and Systems Thinking there, he gained his Ph.D. in Cognitive Systems Engineering from The Ohio State University, USA. He has worked in New Zealand, the Netherlands and England, been Senior Fellow at Nanyang Technological University in Singapore, Visiting Academic in the Department of Epidemiology and Preventive Medicine, Monash University in Melbourne, and Professor of Community Health Science at the Faculty of Medicine, University of Manitoba in Canada. Sidney is author of several best-selling books on system failure, human error, ethics and governance. He has been flying the Boeing 737NG part-time as airline pilot for the past few years. The OSU Foundation in the United States awards a yearly Sidney Dekker Critical Thinking Award.
Reviews: 'Sidney Dekker's book is a thought-provoking exposition of the concept of a just society. Would that we could achieve it! The questions that the author raises need to be discussed at all levels of government, and by judges and lawyers, and by ministers of health. Dekker makes it clear that profound changes must be made in both the legal and the medical systems if we really wish to improve medical safety.'
John W. Senders, University of Toronto, Canada
'A timely book about the current major safety dilemma – how do we resolve the apparent conflict between increasing demands for accountability and the creation of an open and reporting organisational culture?
Thought-provoking, erudite, and analytical, but very readable, Sidney Dekker uses many practical examples from diverse safety-critical domains and provides a framework for managing this issue.
A 'must-read' for anyone interested in safety improvement, but also, one hopes, for politicians, law-makers and the judiciary.'
Dr Tom Hugh. MDA National Insurance Ltd, Sydney, Australia
'With surgical precision Sidney Dekker lays bare the core elements of a just culture. He convincingly explains how this desired outcome arises from a combination of accountability and (organisational) learning. The real-life cases in the book serve to drive his arguments home in a way that will be easily recognised and understood by practitioners in safety-critical industries, and hopefully also by rule makers and lawyers.'
Bert Ruitenberg, IFATCA Human Factors Specialist
The airline industry is under immense pressure and is full of sometimes serious contradictions. 'Staff are told never to break regulations, never take a chance yet they must get passengers to their destination on time. Staff are also implored to pamper passengers yet told not to waste money. The contradictions are at worst a receipt for disaster and at best low staff morale and lead to dishonesty as staff fear consequences and for good reason. Just Culture is essential reading for airline managers at all levels to both understand the endless conflicts that staff face trying to deliver the almost undeliverable and to reconcile accountability for failure with learning from that failure. A soul searching and compelling read.'
Geoffrey Thomas, Air Transport World
'This book is both well-written and well-structured. It gives multiple perspectives on the complex issues of a just culture. The author greatly emphasizes on the down side of the blaming and punishing culture, and consistently proposes the new view of human errors. The given real examples make the points of the author very clear and applicable. The story-telling approach is definitely complementary with the stimulating questions of which the author uses as his writing style.
Beginners and students in the human error field may benefit the most because this book is easy to read but without ignoring the significant details. Nevertheless, all of the professionals in high risk organizations and those who work in the name of justice may find this book as a thought provoking book and particularly as a guidance to build better safety systems where a just culture is practised.'
Newsletter of the Europe Chapter of the Human Factors and Ergonomics Society, September 2008
'This book is fascinating because it is simply written and makes you understand the world of the judiciary and why "an honest mistake" can become a crime. A must-read for every regulator and Ops Manager if we want to retain our present incident reporting systems as a major contributor to safety.'
The Controller, 2008
'HF/E practitioners bring a unique perspective to professionals operating in a particular setting, and this book makes compelling reading for anyone interested in complex social-safety environments.'
Ergonomics in Design, Winter 2009
'It is unusual to find a book about a highly complex, brain-taxing subject which is not only enlightening but also a pleasure to read.'
RoSPA Occupational Safety & Health Journal June 2009
'…this book could and should be read by the policy formers and decision makers of all medium and large enterprises. In doing so they will gain a great deal of insight into an area that has perhaps been neglected for too long. I cannot recommend this work highly enough.'
Health and Safety at Work August 2009
'The author explains that unjust responses to failure are rarely the result of a bad performance; they are rather the result of bad relationships. He suggests that working on improving relationships between managers and employees, doctors and patients, the judiciary system and a profession, is one of the ways we could build a just culture.'
Care Management Journal Vol 10 no 4 2009
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Full contents list
Preface
Index
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