0 nsr/safety en nsi/kwaliteit & veiligheid just culture in action? operationalization of the...
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1NSR/Safety en NSI/Kwaliteit & Veiligheid
Just Culture in action?
Operationalization of the‘Just Culture concept’ at Dutch Railways
Merlijn Mikkers, Safety Advisor Dutch RailwaysFrank Guldenmund, Delft University of Technology
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2NSR/Safety en NSI/Kwaliteit & Veiligheid
Topics
• Safety culture and Just culture
• How to operationalize the just culture concept?: the just culture guideline
• Experiences
• Conclusion
• Discussion
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3NSR/Safety en NSI/Kwaliteit & Veiligheid
Safety culture subject in investigations after major disasters since mid eighties
Chernobyl, 1986
BP Texas, 2005Challenger,
1986
Piper Alpha, 1988
The concept of Safety culture
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4NSR/Safety en NSI/Kwaliteit & Veiligheid
If this openness is not part and parcel of the safety culture, there is the risk of:
• Limited information flow
• Top management less aware of what is happening in organisation
• Disturbed relation between (first-line) employees and management
Openness and honest disclosure amongst employees in an organisation is an important precondition for (organisational) learning
(Bloomfield, 2003)
Openness is a precondition for a mature safety culture
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5NSR/Safety en NSI/Kwaliteit & Veiligheid
Justness towards employees part of safety culture
Just culture part of both organisational and safety culture
Safety culture
Organi-sational culture
Just Culture
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6NSR/Safety en NSI/Kwaliteit & Veiligheid
Organisational triangle
structure
culture processes
Be-haviour
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7NSR/Safety en NSI/Kwaliteit & Veiligheid
Processes
Structure Culture
Synergy between organisational elements
structure
culture processes
Be-haviour
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8NSR/Safety en NSI/Kwaliteit & Veiligheid
Processes
Structure
Synergy between organisational elements
structure
culture processes
Be-haviour
Culture
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9NSR/Safety en NSI/Kwaliteit & Veiligheid
Culture
Processes
Synergy between organisational elements
structure
culture processes
Be-haviour
Structure
• To create a just culture, a holistic approach is necessary
• Organising the process and anchor this in a structure helps to promote ajust culture
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• Starting point is that every incident (for example SPADs) needs to be contemplated
with all contextual factors
• Individual actions are always discussed with reference to the total system in which
they were taken
• The guideline does not provide a dividing line between ‘acceptable’ and not
‘acceptable behaviour’ (or a human error classification scheme)
• Instead, it describes the process that needs to be followed
when an incident happens
Just culture guideline at Dutch Railways
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11NSR/Safety en NSI/Kwaliteit & Veiligheid
• Decision process about the future employability and whether certain actions need
to be taken for future employability and what research questions need to be
answered in the incident investigation
• In that way, the guideline is linked to the incident investigation procedure of the
safety management system of Dutch Railways (anchoring in a structure)
• The role of consolation (by the team manager of the involved employee) and the
manager that participates in the committee are strictly separated
Just culture guideline at Dutch Railways
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12NSR/Safety en NSI/Kwaliteit & Veiligheid
The guideline is structured in three ‘responsibilities’:
Just culture guideline at Dutch Railways
Investigation:
Safety department
Advise:
Advisory committee
Decision making:
Management
Information (based on interview)
Research questions
Advise about future employability
• Committee members: safety expert, peer of the involved employee (for example a
train driver in case of a SPAD), human resources officer and manager
• So, ‘different perspectives’ are represented in the advisory committee
• Balancing thoroughness of the advice needs to be balanced with the fact that the
employee involved is uncertain about whether or when (s)he can perform his or her
job again
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13NSR/Safety en NSI/Kwaliteit & Veiligheid
Just culture guideline at Dutch Railways
A key question that the committee has to answer is the so-called substitution question:
Would a different person have made the same mistake under the same circumstances?
• This question is answered in relation to the complex contextual and individual factors that
have played a role
• If (targeted) individual actions seem necessary, this will be done to improve safety and to
help the employee to improve his or her performance
• Punish employees will only be done in cases of malfunction (for example alcohol
consumption during service)
A tool / document with background information and tips is developedto stimulate discussion in the committee
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Experiences with using the guideline
• It is important to balance the aim of the Just Culture guideline
with the description of practical and juridical implications
• Use the guideline as a ‘guide’line, not as ‘regulation’
• Involving a ‘peer’ in the committee is experienced (also by management) as significant
added value
• Employees that participate in the committee need to be trained, this is part of the
implementation process
• The results of a questionnaire show that the guideline is experienced as positive and
helps to shift the focus
• from the individual component to system components and
• from punishing individuals to actions that improve the system
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Conclusions
• The approach of organising the process and anchor this in a structure, instead of
beforehand drawing a line between ‘acceptable’ and ‘not acceptable’ behaviour seems
successful
• Including a peer in the advisory committee is experienced as very positive
• There are some clues that indicate that it helps to create more openness
• Development and implementation of a ‘Just Culture guideline’ should be a collaborative
process, with management, safety staff, work’s council, and so on
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Discussion / Questions