S5 Box



Compiled by ~ Vanlallian Valte
Up until the scientific revolution in the 17th century, concept of ‘accident/incident’ had no takers. Religion and superstitions explained everything. Early 20th century saw trilogy of time, space and God being considered as what precipitated accidents.  However, in the last 40-50 years, interpretation of accidents has seen dramatic shifts. Three Milestone nuclear accidents: Chernobyl, collision at Tenerife and, Challenger crash moved accidents out of pure ‘Godly’ control to scientific analysis. Accidents were no longer uncontrollable and unfortunate events. Issue of risk and mismanagement of risk were the plausible explanations. Mismanagement of risk was attributed to an individual or a group of people. Society and organizations wanted to find out who didn’t do his job. The ‘accident’ was put against their names. This gave rise to demand for ‘consequences’ for those who ‘crossed the lines and these lines were drawn differently every time. This led to the genesis of Just Culture.
Just Culture: A daily challenge in safety critical domains is to get people to talk about safety problems. Generally people follow the ‘code of silence or Omerta.’ This code is enforced in many ways and for many reasons.  Generally, two types of reasons stand out – I will get into trouble & there is no assurance that information will be safe – people simply don’t trust. Just Culture emphasizes that anyone; even competent professionals can commit mistakes. It recognizes that individual practitioners should not be held accountable for system failings over which they have no control. It believes that errors are the outcome of interactions between human operators and the systems in which they work.


Safety Culture has many stages ranging from pathological to Generative. In Generative Culture, safety is embedded in every action. Just Culture is that evolutionary step which ushers and sustains Generative Culture. The basic essence of just Culture is ‘you do your entrusted job diligently, if there is a mistake or an error – own up truthfully, and you will be treated justly.’ This concept is broadly characterized by following aspects:-
1. Just culture believes that mistakes can be made by any one.
2. The honest mistakes/errors are a building block of an organization. Mistakes are treated as an important source of learning.

3. Just Culture is not a blameless culture. The consequences of errors and mistakes are based on the intent and not the outcome.
4. Willful violations are not tolerated in Just Culture.
5. Just Culture is to provide ‘justice’ and is not to be used as a ‘mitigating tool’ to condone mistakes, errors or violations.
6. The stepping stone for effective implementation of Just Culture is the creation and sustenance of an environment where people can own-up mistakes. In other words, it is an environment of trust.
7. Maturity and success of Justice Culture depends on individual’s self-discipline and organization’s maturity and consistency in handling mistakes and errors.
8. ‘Fear of punishment/consequences’ withholds an individual in sharing his mistakes. He can overcome the same by noticing the steadfast consistency and professionalism of the organization in handling of the information provided by the individual.
9. In a true Just Culture, the individual providing information about his/someone else’s error are not ridiculed or harassed.
10. The decision making authority in Just Culture encourages people coming forward with information.
11. Just Culture is meant to be used in every sphere of activity and it cannot be confined to a particular domain.
Selected Quotable quotes:
1) Not being able to find a cause is profoundly distressing; it creates anxiety because it implies a loss of control. The desire to find a cause is driven by fear - Air Mshl Daljit Singh PVSM, AVSM, VM (Retd)
2) Unjust responses to failure are almost never the result of bad performance. They are the result of bad relationships - The Albatross.

3) Accidents are no longer accidents at all. They are failures of risk management - Sidney Dekker.

4) People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right?  Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue - Don Norman.

5) Accountability that is backward-looking (often the kind in trials or lawsuits) tries to find a scapegoat, to blame & shame an individual for messing up. But accountability is about looking ahead. Not only should accountability acknowledge the mistake and the harm resulting from it, it should lay out the opportunities (and responsibilities!) for making changes so that the probability of such harm happening again goes down - Sidney Dekker.
6) Error is pervasive. The unexpected is pervasive. What is is not pervasive are well-developed skills to detect and contain these errors at their early stages. The essence of safety cultures is to make such skills pervasive - Karl E. Weick
7) Learn from the mistakes of others. You can’t live long enough to make them all yourself – Eleanor Roosvelt.
8) There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight. It is essential that the critic should keep himself constantly aware of that fact - Sidney Dekker.
9) Fear of punishment creates an apprehension human brain. This gradually shifts the focus from 'relevant' to 'not so relevant' agenda - Sqn Ldr NK Rath.
10) The main question for a just culture is not about matching consequences with outcome. It is this: Did the assessments and actions of the professionals at the time make sense, given their knowledge, their goals, their attention demands, and their organizational context - Sidney Dekker.

11) Protecting those who disclose (information) matters just as much. The demand to disclose may not have given an individual’s confidence that honest disclosure would be treated fairly. Creating a climate in which disclosure is possible and acceptable is the organization’s/society’s responsibility. And more protections are often necessary –Anonymous.
VV’ Laidiip/02012017