1. Just Culture / No Blame Environment for More Effective Investigations
Establishing a
Just Culture / No Blame Environment
for More Effective Investigations
Jim Whiting
Principal Risk Engineer & MD
pty ltd, Australia
Blame / Accountability / Just Culture
Group Exercise

2. A ray of hope? Article scanned from “The Age” Melbourne 28 April 1999
Photo ABC News website

3. Value people because they are people
(not resources).
In business-speak, people are referred to as “resources”
Resource: an item deployed to achieve an end.
If we continue to call them “human resources”
we will never think of them as people.
Photo by Permission of Peter Jarver

5. A )
See below some examples of “common” spoken or written expressions
( Used in ALL aspects of our lives - not just our work experiences ! )
which we often use to indicate blame after and before incidents / accidents.
Examples :-
1) Who did it ? Someone is going to pay for this
2) Whose to blame ? / Who was at fault ?
3) Whose shift / roster was it ? Which contractor ?
4) Who can we sue for this ? – It wasn’t my fault !
5) Who can we blame / hang / sack / fire for this ?
6) If there is any kind of stuff-up / goof-up, you’re going to pay for it !
7) What an idiot ! That’s common-sense ! He/She is a qualified ....
8) He/She is accident-prone ! He takes risks he shouldn’t .
9) YOU have a serious accident in YOUR area and you are !!
10) A “hero” takes risks other ‘normal’ people wouldn’t
Brainstorm (with your group) to suggest some more from your own experiences
11)
12)
13)

6. B)
Which of the expressions in A) are Reasonable ? Acceptable ?
in your organisational culture ?……………………………………………… C)
i) What are the differences between blame and accountability ?
ii) If you are given a responsibility to fulfill ( i.e. a job to do ) and you agree that you have been given adequate au………….? to do it , is it fair and reasonable for you then to be held accountable if you don’t fulfill the responsibility ? Keep these 3 words together D)
i) Can an organisation have accountability without blame ?
ii) Is unfair accountability really nothing else but blame? E)
i) Can the expressions “no blame” or “blame-free culture” be wrongly taken by some employees as meaning “no discipline” ? ………………………….
ii) Which of the expressions:- “no blame culture” or “blame-free culture” or “fair culture” or “just culture” or “ accountability without blame” is best for you …..?

7. Would you say your company’s response to incidents is mainly F)
Would you say your company’s response to incidents is mainly
punitive ? or learning ? G)
What are the differences between“ error” /“intentional rule violation”?
ii) When does behaviour become “reckless conduct” ? or “negligent conduct” ?
iii ) After an accident involving any combination of the 4 behaviors above,
what is the appropriate disciplinary response ( if any ) to each of the 4 ? ……………
iv) what happens in most organisations ? ……………………………………
v) Is an error a consequence or a cause ?……………………………………… H)
How many adjectives are used in front of the word “cause” ? Can we use less of them ? root, contributory, main, only, significant, proximate, immediate, active, latent, systemic.... I)
How is all the above relevant to :-
“ incident investigation ” and “ problem solving ” ?
For a copy of PowerPoint - contact
Jim Whiting