1. 0 NSR/Safety en NSI/Kwaliteit & Veiligheid Just Culture in action? Operationalization of the ‘Just Culture concept’ at Dutch Railways Merlijn Mikkers, Safety Advisor Dutch Railways Frank Guldenmund, Delft University of Technology

2. 1 NSR/Safety en NSI/Kwaliteit & Veiligheid Topics Safety culture and Just culture How to operationalize the just culture concept?: the just culture guideline Experiences Conclusion Discussion

3. 2 NSR/Safety en NSI/Kwaliteit & Veiligheid Safety culture subject in investigations after major disasters since mid eighties Chernobyl, 1986 BP Texas, 2005 Challenger, 1986 Piper Alpha, 1988 The concept of Safety culture

4. 3 NSR/Safety en NSI/Kwaliteit & Veiligheid If this openness is not part and parcel of the safety culture, there is the risk of: Limited information flow Top management less aware of what is happening in organisation Disturbed relation between (first-line) employees and management Openness and honest disclosure amongst employees in an organisation is an important precondition for (organisational) learning (Bloomfield, 2003) Openness is a precondition for a mature safety culture

5. 4 NSR/Safety en NSI/Kwaliteit & Veiligheid Justness towards employees part of safety culture Just culture part of both organisational and safety culture Safety culture Organi- sational culture Just Culture

6. 5 NSR/Safety en NSI/Kwaliteit & Veiligheid Organisational triangle

7. 6 NSR/Safety en NSI/Kwaliteit & Veiligheid Processes Structure Culture Synergy between organisational elements

8. 7 NSR/Safety en NSI/Kwaliteit & Veiligheid Processes Structure Synergy between organisational elements Culture

9. 8 NSR/Safety en NSI/Kwaliteit & Veiligheid Culture Processes Synergy between organisational elements Structure To create a just culture, a holistic approach is necessary Organising the process and anchor this in a structure helps to promote a just culture

10. 9 NSR/Safety en NSI/Kwaliteit & Veiligheid Starting point is that every incident (for example SPADs) needs to be contemplated with all contextual factors Individual actions are always discussed with reference to the total system in which they were taken The guideline does not provide a dividing line between ‘acceptable’ and not ‘acceptable behaviour’ (or a human error classification scheme) Instead, it describes the process that needs to be followed when an incident happens Just culture guideline at Dutch Railways

11. 10 NSR/Safety en NSI/Kwaliteit & Veiligheid Decision process about the future employability and whether certain actions need to be taken for future employability and what research questions need to be answered in the incident investigation In that way, the guideline is linked to the incident investigation procedure of the safety management system of Dutch Railways (anchoring in a structure) The role of consolation (by the team manager of the involved employee) and the manager that participates in the committee are strictly separated Just culture guideline at Dutch Railways

12. 11 NSR/Safety en NSI/Kwaliteit & Veiligheid The guideline is structured in three ‘responsibilities’: Just culture guideline at Dutch Railways Committee members: safety expert, peer of the involved employee (for example a train driver in case of a SPAD), human resources officer and manager So, ‘different perspectives’ are represented in the advisory committee Balancing thoroughness of the advice needs to be balanced with the fact that the employee involved is uncertain about whether or when (s)he can perform his or her job again

13. 12 NSR/Safety en NSI/Kwaliteit & Veiligheid Just culture guideline at Dutch Railways A key question that the committee has to answer is the so-called substitution question: Would a different person have made the same mistake under the same circumstances? This question is answered in relation to the complex contextual and individual factors that have played a role If (targeted) individual actions seem necessary, this will be done to improve safety and to help the employee to improve his or her performance Punish employees will only be done in cases of malfunction (for example alcohol consumption during service) A tool / document with background information and tips is developed to stimulate discussion in the committee

14. 13 NSR/Safety en NSI/Kwaliteit & Veiligheid Experiences with using the guideline It is important to balance the aim of the Just Culture guideline with the description of practical and juridical implications Use the guideline as a ‘guide’line, not as ‘regulation’ Involving a ‘peer’ in the committee is experienced (also by management) as significant added value Employees that participate in the committee need to be trained, this is part of the implementation process The results of a questionnaire show that the guideline is experienced as positive and helps to shift the focus from the individual component to system components and from punishing individuals to actions that improve the system

15. 14 NSR/Safety en NSI/Kwaliteit & Veiligheid Conclusions The approach of organising the process and anchor this in a structure, instead of beforehand drawing a line between ‘acceptable’ and ‘not acceptable’ behaviour seems successful Including a peer in the advisory committee is experienced as very positive There are some clues that indicate that it helps to create more openness Development and implementation of a ‘Just Culture guideline’ should be a collaborative process, with management, safety staff, work’s council, and so on

16. 15 NSR/Safety en NSI/Kwaliteit & Veiligheid Discussion / Questions