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Just Culture making it work Job Brüggen.

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Presentation on theme: "Just Culture making it work Job Brüggen."— Presentation transcript:

1 Just Culture making it work Job Brüggen


3 Questions What IS a Just Culture? Who needs a Just Culture?
Why do WE need a Just Culture? Who is busy with a Just Culture? How to make and guard a Just Culture? Is there a law on Just Culture? What can WE do for Just Culture?

4 What is a Just Culture? A culture in which frontline operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.“


6 Who needs a Just Culture?
They are humans Humans make mistakes If we want these people to perform these jobs… …we must find a way of dealing fairly and justly with these inevitable errors.

7 Linear model of failure

8 Why do we need a Just Culture?
Where FEAR is leading, people will not learn to improve, but people will learn not to get caught. Learning is safer than punishing!

9 Pro-active learning : ROLES
Managers Workforce Installing trust Risk Awareness Design for safety Facilitate the right choice Effective learning from events Earning Trust Risk awareness Design for safety Reporting Learning Being a role model

10 Just Culture background material
Sidney Dekker. Just Culture. Balancing Safety and Accountability. Amazon Hearts and Minds available at the Energy Institute GAIN [Global Aviation Information network] A Roadmap to a Just Culture. Enhancing the Safety Environment.  Baines & Simmons. FAiR® System (Flowchart Analysis of Investigation Results) Reason. Managing Risks of Organizational Accidents.Amazon. Reason. Human error: models and management.  Hudson. A new model for a Just and Fair Culture. Hudson. Safety Culture – Theory and Practice Eurocontrol Skybrary - Link to Just Culture material Eurocontrol. Establishment of Just Culture principles in ATM safety data reporting and assessment. Mateou. Flying in the Face of Criminalization. The Safety Implications of Prosecuting Aviation Professionals for Accidents David Marx. Whack a mole. The price we pay for expecting perfection. Eurocontrol. Just Culture Guidance Material for Interfacing with the Judicial System European Commission: EU REG 2003/42 European Commission: update ICAO Safety Of Information Protection TaskForce Eurocontrol Just Culture Policy

11 How to create a Just Culture?
Policy What you want to achieve: a learning culture. Better one lesson learned, then ten people punished. Definitions : What is good behaviour What is bad behaviour What you will do with BOTH Procedures Define WHO gets to say what is right and wrong Involve the workforce! Show good leadership Lead by example: it is NOT only about the workforce


13 Tools to help classify behavior
Flavors: Crude Old Complex Useful

14 David Marx-Just Culture Community

15 David Marx-Just Culture Community



18 Baines & Simmons

19 Baines and Simmons


21 Hearts and Minds

22 Hearts and Minds


24 Eurocontrol Just Culture Task Force
Just Culture Model Policy Coordination Just Culture and related activities: In Europe with EU, EASA, ECAC In ICAO and global regions Model for a National Aviation Prosecution Policy To be discussed and implemented at National or Regional level Support to the Judiciary: Dedicated experts course for assisting Judiciary European initiatives for establishing a dialogue between safety and judicial experts

25 Netherlands’ law Implemented EU Directive on Aviation Reporting
Includes protection for reporters Restrictions for prosecutor Willful misconduct and gross negligence excluded!

26 Now, what can WE do? We shall start with OURSELVES

27 SOCIETY service service Safety rights Justice rights beliefs beliefs

28 Internal Just Culture first
Give people trust so they action their good intentions over and above their emotions. Better safety performance Your Just Culture adopts already parts of the classical beliefs of criminal justice. Justice officers will better trust your system A good INTERNAL Just Culture assists a good EXTERNAL Just Culture

29 Easy cases are … well, easy.
UP WINGS FALL OFF STOP WINGS STAY ON DOWN SEAT RECLINE SWITCH Honest mistake Reckless behavior …but where is the real line between honest mistake and culpable behavior?

30 Interpreting human behavior
“The line” is drawn in 256 shades of gray! INTENT is what counts, not the outcome Reward and stimulate positive behavior What about the (non-)actions of the manager?

31 Sharing practical experience handling (internal) Just Culture issues Multiple fields Healthcare Processindustry Aviation Interactive Smartphone-ready (Just Culture in your pocket!) Expansions to Inspection, Prosecutor roles (future)

32 The background Based on JC “models” and theory Synthesis James Reason
David Marx Baines & Simmons Hearts & Minds Sidney Dekker Synthesis Avoid too simplistic views Take out overcomplicated theories Emphasize the positive side Include the management

33 Navigator

34 The website

35 Just Culture in your Pocket

36 Now what is your status? Fallen asleep
Stayed awake but did not understand Yeah interesting, thanks I am going to do something with it.

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