Just culture’s ‘‘line in the sand” is a shifting one; an empirical investigation of culpability determination
[This is an update and repost of an older post but now in article format]
This surveyed 3136 aviation maintenance personnel from one company to judge the appropriate level of discipline in 3 incident scenarios. Five pieces of ‘‘mitigating” contextual information were presented per scenario and the participants given an opportunity to re-assess their judgement of culpability/discipline.
First, the issues with Just Culture (JC) processes were highlighted. Including the fallacy of JC appearing to be objective rather than a judgement of social construction. Or how acceptable or unacceptable behaviour are not stable categories with fixed features independent of context.
Also, the evidence was discussed that shows the order of info, how it’s presented, and other characteristics influence culpability judgements (including things like outcome bias). This includes:
Results
Although there were differences b.t. responses in each scenario, and some individuals were markedly different, mostly people responded similarly per scenario in alignment to JC culpability principle; suggesting a sense of shared thinking around culpability and discipline.
The authors conclude that the JC process is not an objective system that can simply be implemented; it is social and organisational of negotiating meaning. Further, based on their findings they question whether JC tools can be reliably used or if they serve a useful purpose in managing safety.
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Judgements on culpability became more lenient as additional info was provided. However, in each scenario there was one piece of info that consistently led to more severe ratings of discipline – so called “anti-mitigating” factors.
There appeared to be no consistency to the type of info that led to this, except for the fact that this one factor was an external factor outside the direct control of the implicated employee. Authors speculate that perhaps participants draw a line between what they see as genuine circumstances or excuses.
European sites were significantly more lenient than North American sites.
Engineers and managers were more lenient than operational staff, and more experienced personnel more lenient than juniors. Engineers were the most lenient; whereas management were more severe on other senior managers.
Interestingly, quality and safety personnel appeared to be the most severe in judgement – but this was not statistically significant (which the authors believe was due to the small sample size).
Unexpectedly, the consequence of the incident to the company doesn’t appear to have influenced the participants. Participants were more sympathetic to issues that they perhaps had exposure to (poor IT systems, lack of supervisor, family pressures). Moreover, the seniority and level of responsibility of the target individual was important in participants’ assessments of discipline – where they were harshest on managers and the most lenient on new hires.
Link in comments.
Authors: Cromie, S., & Bott, F. (2016). Safety science,?86, 258-272.
Director, Verda Consulting. Supporting your business through enhanced safety performance.
2 年Having been exposed to JC for close to 20 years I must say it saddens me that standard JC discourse includes terms such as discipline, the line in the sand, process etc. It has now given birth to the term retributive Just Culture which for me is incongruent. The debate about 'those flowcharts' (often referred to as a JC process) are sucking the life out the original intent. Covering less than 0.5% in Reasons works they certainly do a good job at trying to garner the spotlight. It's not to be denied that the minute a flowchart was available it would become a defacto process. My experience shows that they get published in manuals with little buy in, little understanding of key dependencies and rarely does the use of such get scrutinised proactively. When I have spoken of JC with clients they grab the flowchart! Prone to drift through lack of purpose and ownership it is no surprise where we are. No different to any other tool... Risk assessment, investigations etc. . The reality we see is not what was intended - given we are 25 years into the JC journey and it appears we have not moved much: we have to look beyond flowcharts and seek solutions to strategic blockers.
MarmiteDiva.blogspot.com/ All views expressed are mine and mine alone. Writer. Campaigner. Philanthropist
2 年Thank you Ben Hutchinson . I need to read this again and more slowly; the first thing to spring to my mind in the meantime is the 'resilience' of 'victims' and how they report indiscretions. An identical situation might be reported very differently by two different people, which would further complicate an already complex situation.
HSE Leader / PhD Candidate
2 年Nippin Anand, Diane Chadwick-Jones this may interest you if you've not yet read it
HSE Leader / PhD Candidate
2 年Study link:?https://doi.org/10.1016/j.ssci.2016.03.012 My site with more reviews: https://safety177496371.wordpress.com