Customer Reviews

Just Culture: Balancing Safety and Accountability

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This book offers the following important insights:

"Just Culture" is an abstract phrase, which in practice, means that getting to an account of failure that can both satisfy demands for accountability while contributing to learning and improvement.

Professionals in safety critical industries receive two messages, "Don't ever compromise safety!" but also, "Be productive, don't cost us money!"

Reasons why professionals report, and reasons why they don't

Suggestions for improving reporting rates (maximizing accessibility and minimizing anxiety, sending feedback about what has been changed in light of the report)

The results of a reporting system where employees report to their direct supervisor versus a member of the safety/quality staff

The difference between disclosure and reporting

The categorization of errors as either technical or normative (and how the same actions before an outcome can be labeled as either, depending on who draws the line in your organization)

The pervasiveness of hindsight bias and suggestions for how to minimize it's effect on decisions made from reporting

The definition of negligence and how it can be interpreted differently by looking at the actual words in the definition

The book also delves deeply into the legal ramifications of incident reporting. This is very interesting for the policy wonks among us; less so for those who are looking to this book for practical suggestions for implementing a "just culture" in their organization.

I got Sidney's book from Ashgate a couple of weeks back. Never thought to check it out from the Library as Captain Sullenberger did. Those Captains think in multiple dimensions! I just finished it and it will be an essential text to guide organizations through the establishment of a functional safety management system (SMS). SMS will not prosper if you do not have sound policy, robust reporting, comprehensive risk management and a quality assurance and audit program. The only way to optimize those programs is to have an open and honest organizational reporting culture.

The "just culture" philosophy asks thought provoking questions of how society treats failure with blame, when instead accountability should be used proactively and collaboratively to improve a system and prevent future mishaps. A "zero-defect" mentality is not reality, in any organization or society. In a just culture we can share information to educate an organization, and industry, a nation and prevent mistakes that cost lives and damage property.

Just Culture discusses the option of working together to make each others' lives better, to look out for one another. The last chapter is especially germane, as it offers a model approach to building a just culture at home, in your organization and in your country. Sidney's book will answer the many nagging questions that you have about how and why we hold people responsible for failures of a system.

Kent Lewis
Captain USMC (Retired)
www.signalcharlie.net

Bad stuff happens to good people. The truth turns into people's versions. Something serious can draw media and even court attention. A code of silence typically ensues because it is to easily to be unjustly accused. And it is no wonder why this happens. Rather than increase reporting of accidents, the author suggests that we generate a culture of honestly disclosing accidents with the only intention of learning to avoid repeated mistakes.

The book is littered with examples from real cases where ethics and legal issues collide. My heart poured to repeatedly see how people are punished for their unknown involvement in a supposed crime.

Just Culture is about accountability, therefore trust. Without respect for the worker and an understanding of the system they work in along with a devotion to improving the system the worker works in - there will be no accountability - no ownership. The author repeats his praise for learning. A very lean message indeed. If your team discusses near misses, authentically, you are already on your road to blameless learning when incidences occur.

Forward looking accountability ensures someone is responsible for reducing the probability of a repeat. Getting this in your organization is laid out in the last chapter. Throughout the book are tips on how to avoid not having a just culture: bad morale, low commitment to the organization, poor job satisfaction and a low level of willingness to do that little bit extra.

Don't forget to read in groups and discuss what to do together if you really want to make a difference.

This book describes an "alternative way" to approach an accident (or near-miss or unintended outcome) by telling us to view the event as a signal or warning that there are risks involved in our work that we have not correctly understood or are not managing the way we imagined. This approach changes the nature and the goal of the investigation process. Accidents, and especially close calls, become essential organizational learning opportunities. Accountability is about looking ahead.

A philosophical look at accitdents primarily in the aviation and medical fields. Our culture is to spend more effort fixing blame than fixing the problem so it will not happen again. Applicable to the culture in many fields not only aviation and medical. Worth reading.

Title says it all. Captain Sullenberger intended to read this book on the famous flight. He left it on the plane ...