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Old 8th Mar 2017, 10:50
  #905 (permalink)  
safetypee
 
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Chugalug2, #904. The objective of my quotes and questions in #884 was to seek debate.
Very few issues in life are absolute; your views appear somewhat extreme, although I would agree with the sentiments and direction of the argument.

An alternative position is that Just Culture is an unobtainable academic concept; a top down view of human activity to achieve unvalidated objectives. The idea that self reporting will provide insight to human behaviour is flawed (IMHO), although other activities may have value - Creating a learning culture, Designing safe systems, Managing behavioural choice. (Ref *) Note "knowing that systems / human will never be perfect" slides 11/12.
Subsequent slides are equally important - 'JC is about' (20-22): Understanding risk and risk management, Changing managerial expectations.

The span of the JC issue ranges retributive to restorative, the key point is where an organisation's culture is positioned, remembering no absolutes.
Military views will by nature tend to retributive; a more focussed discipline in training, yet enabling (encouraging) variability and adjustment as required by the situation (e.g. war), thus there is greater focus on teaching / acquiring / reinforcing skills of judgement - but where 'punishment' might be used as reinforcement agent. Is this event one of learning or punishment?
The CM relating to this incident reflects a retributive culture. The thread discussion relates to the degree of punishment, which appears biased by hindsight, severity-outcome bias, and considering the resultant vice the behaviour. This judgment depends on who and when it is made - "who draws the line" (S. Dekker).

There is no objection to outlining problems - 'what's wrong', but not who as that might curtail restorative activity. The really important issue is how we might improve - safety, attitudes, behaviour.
I don't have a solution, but I am prepared to consider alternatives, new views of error, the human as an asset, work as actually done.

Is military management (RAF) sufficiently flexible or willing to consider alternatives, have they forgotten the caveats of military training re adjustment vs discipline (new views), is man management seen as the control of a hazard or managing valuable assets, are they close enough to the front line (work as done).

The learning value in this incident is that a small margin in judgement can have serious unforeseen consequences, either in the air or in managing policy relating to punishment.

Ref * https://www.unmc.edu/patient-safety/...st-culture.pdf
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