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Human Factors & System Safety

Faculty of Engineering, LTH

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Just Culture: Balancing Safety and Accountability

2007

Ashgate Publishing Co.
www.ashgate.com  

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.

'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

The book “Just Culture” by Lund University Professor Sidney Dekker, presented to Capt. Sullenberger during a ceremony in New York.

 

During an award ceremony in New York’s City Hall on Monday February 09, the US Airways crew, that recently successfully landed the A 320 aircraft onto the Hudson River, was awarded keys to the city of New York by Mayor Michael Bloomberg.

In conjunction with this, Bloomberg also presented the book “Just Culture" to Capt. Chesley “Sully" Sullenberger, who had to leave his copy on board the aircraft.

“Just Culture: Balancing Safety and Accountability" is written by Professor Sidney Dekker, Director of Research at Lund University School of Aviation, Sweden.

The book focuses partly on how responses to incidents and accidents, that may be perceived as unjust, can create fear and silence and reduce willingness to report, rather than learning and improving.

In a time, when it is more and more common to treat human error as a crime, it is an interesting reading material not just for airline pilots, but for all people in safety-critical work.

CNN video clip: "’Miracle' flight crew honored"