The concept of a just culture is one of those unattainable ideals, which represent the gap between theory and practice.
A just culture is not something you have; it’s like safety, it’s something you do.
Similarly, definitions of what should be done are not a great help, particularly where the managing individuals hold the definition, and where judgement is always with hindsight. Drawing a line is not important; it’s who draws the line (Dekker).
The key issue is not the submission of reports, but how they are handled by individuals. Will those who manage be free from bias; do they have and apply sufficient human factors knowledge in their judgements, do they have sufficient role and situation experience – including that of ‘error’.
Do the operators at the sharp-end have similar qualifications so that they can draw their own line, but in this instance in real time.
If the sharp-end can be provided with the means of ‘doing the right thing’ for the situation, context, and within the limits of human performance, then there should not be any need to judge individual performance after the fact. However, situations and human performance are never clear-cut, thus the managerial judgement must have similar provisions for ‘doing the right thing’.
This requires training and knowledge in the skills of human performance, primarily for the blunt-end, because if the sharp-end activities result in ‘crossing a line’, then it’s more than likely that management have accountability for ‘the line’ and many of the situational contributions to human performance.
Management should consider that there is
no such thing as error. Instead substitute ‘variable human performance’ which might trigger an alternative way of thinking about people and safety in general. Then perhaps we won’t need to ‘create’ the concept of a just culture; instead use a new way of thinking about safety.
For staff college reading
The ETTO Principle.
and
“… we must all be held accountable for our efforts to make the system safer”
.