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.“
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 ManagersWorkforceInstalling trustRisk AwarenessDesign for safetyFacilitate the right choiceEffective learning from eventsEarning TrustRisk awarenessDesign for safetyReportingLearningBeing a role model
10 Just Culture background material Sidney Dekker. Just Culture. Balancing Safety and Accountability. AmazonHearts and Minds available at the Energy InstituteGAIN [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 PracticeEurocontrol Skybrary - Link to Just Culture materialEurocontrol. 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 AccidentsDavid Marx. Whack a mole. The price we pay for expecting perfection.Eurocontrol. Just Culture Guidance Material for Interfacing with the Judicial SystemEuropean Commission: EU REG 2003/42European Commission: updateICAO Safety Of Information Protection TaskForceEurocontrol Just Culture Policy
11 How to create a Just Culture? PolicyWhat you want to achieve: a learning culture.Better one lesson learned, then ten people punished.Definitions :What is good behaviourWhat is bad behaviourWhat you will do with BOTHProceduresDefine WHO gets to say what is right and wrongInvolve the workforce!Show good leadershipLead by example: it is NOT only about the workforce
24 Eurocontrol Just Culture Task Force Just Culture Model PolicyCoordination Just Culture and related activities:In Europe with EU, EASA, ECACIn ICAO and global regionsModel for a National Aviation Prosecution PolicyTo be discussed and implemented at National or Regional levelSupport to the Judiciary:Dedicated experts course for assisting JudiciaryEuropean initiatives for establishing a dialogue between safety and judicial experts
25 Netherlands’ law Implemented EU Directive on Aviation Reporting Includes protection for reportersRestrictions for prosecutorWillful misconduct and gross negligence excluded!
26 Now, what can WE do?We shall start with OURSELVES
28 Internal Just Culture first Give people trust so they action their good intentions over and above their emotions.Better safety performanceYour Just Culture adopts already parts of the classical beliefs of criminal justice.Justice officers will better trust your systemA good INTERNAL Just Culture assists a good EXTERNAL Just Culture
29 Easy cases are … well, easy. UPWINGSFALL OFFSTOPWINGSSTAY ONDOWNSEAT RECLINE SWITCHHonest mistakeReckless 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 outcomeReward and stimulate positive behaviorWhat about the (non-)actions of the manager?
31 Sharing practical experience handling (internal) Just Culture issuesMultiple fieldsHealthcareProcessindustryAviationInteractiveSmartphone-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 MarxBaines & SimmonsHearts & MindsSidney DekkerSynthesisAvoid too simplistic viewsTake out overcomplicated theoriesEmphasize the positive sideInclude the management