Just Culture: Balancing Safety and Accountability

by Sidney Dekker

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.

Genres: Nonfiction, Management, Leadership, Professional Development, Sociology, Psychology

166 pages, Hardcover

First published December 21, 2007

About the author

Sidney W. A. Dekker (born 1969, "near Amsterdam"),is a Professor at Griffith University in Brisbane, Australia, where he founded the Safety Science Innovation Lab. He is also Honorary Professor of Psychology at the University of Queensland.

Previously, Dekker was Professor of human factors and system safety at Lund University in Sweden,where he founded the Leonardo da Vinci Laboratory for Complexity and Systems Thinking, and flew as First Officer on Boeing 737s for Sterling and later Cimber Airlines out of Copenhagen. Dekker is a high-profile scholar and is known for his work in the fields of human factors and safety.

Reviews

[Morgan Blackledge · Rating 5 out of 5]

Just culture is an organizational approach derived from applied systems theory that assumes mistakes or poor outcomes are a product of poor organizational design, rather than the fault of lazy or careless employees.

Just culture assumes that people come to work to do a good job, and don’t want to make mistakes that would jeopardize their livelihood, safety, or the safety of others.

Individuals in a just culture are still accountable for their misconduct and negligence. But only when misconduct or negligence are ACTUALLY to blame.

Just culture views honest mistakes as opportunities for an organization to (a) learn and (b) adapt by asking ‘what went wrong?’ rather than ‘who fucked up?’ or worse ‘who can we blame this on?’

The important benefit of a just culture is that it’s safe for employees (you know, the people who are actually doing the work) to come forward with their observations and concerns without fear of retaliation and for the benefit of the organization as a whole.

This is a wonderful, concise, useful and enlightening read.

Sidney Dekker is phenomenal.

5/5!!!

[Noladishu · Rating 2 out of 5]

Very dry, but raises some interesting points.

This book got famous because it was what Sully Sullenberger was reading when his plane went down.

[Ciprian Dobre-Trifan · Rating 4 out of 5]

The book presents a very important facts and examples based analysis of the very essence of justice, and how much it needs to change in order to be appropriate for the current complexities and responsibilities of modern professionals and society as a whole.

[Jerry Mahn · Rating 5 out of 5]

Dekker looks at the issue of what organizations do when something goes wrong. Do we find the easiest employee to blame, and fire them, thus feeling we took care of the problem, or do we create a culture in which employees feel empowered to admit mistakes, evaluate the circumstances that led to it, and then learn from the mistake as an organization? Very interesting issues...

[Melchor Moro-Oliveros · Rating 3 out of 5]

Getting more than 4 stars on Goodreads is a very high rating. This book has, as of Sept 2021, a rate of 4,21, which honestly surprises me. To me it is an average book. I’ve given it 3 stars. First because of the language. Having said that I am not a native English speaker, I found the English style tangling. Lot of rare words that you do not find in similar technical books talking about the same subject. Second because of the edition by CRC press: small size characters, no space between lines, almost no page margins at all. It is not a friendly print format.


Ok, let’s now go to the content (you can skip this part): The book brings up the issue in a correct manner: If your organization has a culture of blaming or punishing the workers for making mistakes, it will create an atmosphere in which there will be no trust. As a consequence, workers will not report mistakes openly and hence same mistakes will happen again. Workers will not be willing to take risks and initiative, they will rather be in a position to protect themselves against blaming and punishment. This is true. However, didn’t we all new this already?. Mistakes are typically result of a poor organization and bad processes and not a result of lazy workers who do not care about making their job at theirt best. Also true. But here again, we all know this, I guess. Third thing that the book brings up: If you go into lawsuits you are doomed. When attornies, prosecutors and judges jump in, then the mistake is the least that matters. A show begins of poeple moved by other interests. All right and well known already, but, now what? No real path in the book and no conclusion. I have extracted here and there the following learnings for me:
- Most people suffering the consequences of mistakes at work, specially in the medical system or aircraft industry, want an explanation rather than a punishement to the mistake maker. Have empathy to the victims. Put yourself in their position.
- Work on the root cause. Try to explain why it made sense to do what it was done instead of explaining what went wrong and how it is right.
- Be aware of the hindsight bias: the worst the consequences, the worst the actitude against error makers.
- Get people to report. Spend time and resources and please, build up trust. Do not force behaviours. Keep confidentiallty of reporter.
- Enpower disclosure and pay attention to confidentiality. The world is plenty of “bad” people, specially attornies.
- No matter what we sign up for, whether a simple cellular contract, we always get several paper work to sign which requires our acknowledge to avoid the service provider to be liable for any thing. We sign all although we do not read through it. This is the consequence of blaming/punishing for making mistakes.

The best of the book is on page 126 -127 “Rethoric: The Art of Persuasion”. It is fantastic how it questions the view we have of a crime and a criminal. We see a crime as something “real”, which is the result of material facts (visible, tangible). If the facts are there, then the act is a crime and the actor is a criminal, he or she is inherently a criminal and the act is inherently a crime. Another vision sees a crime as a property now and here, not independently existing. So culpability arises out of ways of putting facts, considerations, cuircumstances toghether and saying “this here and now is a criminal act”. The culpable shall pay for it but it is not that he or she is now found to be a criminal in his inherent personality and forever. Interesting approach. Probably very philosophical.

[Joshua Southard · Rating 5 out of 5]

Working in the aircraft industry can be very challenging. Lives are at stake. Being a big, public company adds financial pressures which can be fickle and immense. Having the right culture is critical. Understanding the culture is often nuanced and complex. Having the right words to express the ideas around culture can be the difference between building a healthy culture and perpetuating an unhealthy one. This book provides frameworks and language to help understand just cultures and unjust cultures. There are many helpful ideas and case studies included, but the biggest lesson I learned was about the balance each company must have between restorative justice and retributive justice. Retributive justice asks “Who messed up and how do we punish them so that justice is served?” Restorative justice asks, “What went wrong, who was hurt, how can we fix the processes, and how can we heal those who were hurt?” Retributive justice often seeks scapegoats. Restorative justice seeks learning and healing. Dekker describes three types of errors or mistakes that can be made in our high-speed work environments: 1) Human errors or honest mistakes. 2) At-risk behavior or errors made by workers dealing with great or unknown risks. 3) Negligence. Workers ignoring risks, rules, or requirements and making decisions that cause harm. The challenge is that it is often hard to draw a line between what is okay and not okay. It is hard to determine where to start consequences. Often our vocabulary and logic fail us and we do more harm than healing when sorting out what to do following an error or mistake. Justice is a matter of perspective. Dekker also spends a lot of time describing the second victims. These are the people who suffer as a result of a mistake, error, or choice they made working in these environments such as a police officer who kills someone in the line of duty, a nurse who makes a fatal medical mistake, or a pilot who causes a crash. These people are often hurt and may spend years suffering from guilt, shame, loss of credentials, jail time, or in the worst cases, they may even take their own lives after an incident. These second victims are often the scapegoats and can be forgotten or abused by retributive justice cultures. Restorative justice cultures seek these victims out too and seek to learn from them and their experiences and use those lessons to fix systems that failed. Dekker describes the following theories which are used to describe why people break the rules or make mistakes: labeling theory, control theory, learning theory, bad apple theory, stupid rules or subculture theory, and resilience theory. I’ve seen examples of all of these at work and in other areas. Understanding them helps give language to some of the interesting psychology they describe. Dekker also talks about the interesting dynamics of reporting and disclosure, and how leaders or regulators can incentivize individuals and organizations to open up about mistakes and learn from them before an accident or legal case forces the action. This isn’t a very long book, but it is packed with good lessons, examples, and language to help understand complex ideas about company cultures. I’ll reread this soon to soak up more of the lessons.

This is for anyone seeking to learn about justice.

[Terry Tucker · Rating 4 out of 5]

This is good reference book. The author uses a number of case studies to illustrate his points. I am in Safety Risk Management. We are always looking for ways to improve the reporting, self-disclosure and investigative process. We use the typical RCA tools that others use - Bow Tie, HFACS, Fish Bone..etc. This booj helps bring together a few of the more esoteric elements that organizations have trouble with. All in all, a good book, it could have been shorter, but then it wouldn't sell as a book and would have been a paper.

[R. · Rating 4 out of 5]

This was the first book that I read on "just culture." I was a bit familiar with the concept of it from some of my co-workers who have brought it with them into our organization but it was really good to have a more detailed and thorough explanation. I agree with it probably . . . 98% of the time I think. There are some exceptions that come to mind and some practical questions about implementation, etc. but I assume that since I've downloaded another half dozen or so books about it I might get some of those answered before I'm done.

[Kai Evans · Rating 5 out of 5]

pretty great. his rhetoric around criminalization of human error is top notch

[Nikki · Rating 5 out of 5]

Great book, well explained and an engaging read

[Vesa Linja-Aho · Rating 5 out of 5]

Short and hands-on introduction to Just Culture in safety. Good storytelling and references.

[Racer_rajesh · Rating 4 out of 5]

Ok book,

[Meghan Smith · Rating 4 out of 5]

A bit dry, but still good. Mostly aimed at higher risk industries, but I was still able to pull some insights and actions for my job.

[Matthew Horvat · Rating 5 out of 5]

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.

[Kate · Rating 3 out of 5]

The book is about how punishing a single person for an unintended loss of life does not help the system (healthcare, air traffic, etc) keep similar incidents from happening again and is inappropriate because that single person is 1) part of a larger system 2) probably trying to be safe 3) also traumatized by inflicting injury unintentionally. The other main idea is that people tend to make judgements based on the outcome rather than on the situations and actions that they are actually supposed to be judging.

These two points are good and the many, many examples used to make the points are captivating, but I felt like the book spent too much time trying to convince the reader of these two points and not enough time helping the reader put in place alternative systems to actually support a more just and accountable culture at their organization. Everything in the book probably could have been edited down to an essay, perhaps a single chapter in a book about workplace culture that has other chapters drawn from edited down versions of other long winded books making 2-3 points over hundreds of pages.

[Gallottino · Rating 4 out of 5]

Un libro controcorrente.
Why do we blame? In this book Dekker starts from a terrible story about a nurse, with 25-years of experience, charged and convicted for manslaughter because she erroneously mixed the wrong dose of xylocard causing the death of a 3 year old baby.
We need to blame to try to explain what went wrong, finding a scapegoat, a bad apple but we never yet understood the lesson. Healthcare is a risky business. A just culture don't blame nobody but searches problems and stimulates incident reporting.
A book useful for many "managers" without culture. Also and above all for italian politicians, judges and journalists.

[Emanuele Gemelli · Rating 5 out of 5]

Another fascinating book from Dekker; plenty of ideas to ponder on and reflect. In my line of job I was already putting under scrutiny the "repercussion" or "retribution" model and this book provides with deep insight on how to move the discussion to the next level. I did non have an answer to people telling me: "sure, no blame, but if he makes a mistake it is fault and he should pay the consequences". Obviously in the realm of safety this never solves anything, but I was finding very difficult to find a good way to move forward. This book proposes this way forward. It will take some time to let my organization digest some of the concepts outlined here, but, I believe, this is the way to go

[Manabu · Rating 4 out of 5]

あくまで「裁けるか」という視点。

[Emmalittle100 · Rating 2 out of 5]

Good read

[Alastair Lack · Rating 4 out of 5]

The quote in another review 'bad stuff happens to good people' is so true, and this should be required reading for every HR manager and CEO. Slightly complex language, but the messages are clear.

[Jac · Rating 4 out of 5]

Must read for everyone working in a high stakes profession, from medicine to mining to aviation. And for lawyers.