Welcome to the Safety and Justice Toolkit.
This toolkit is designed to be a general purpose utility. It does not exclusively follow one of the many models about Just Culture that one can find in literature, publications, magazines, websites or blogs. Where relevant, the toolkit points users towards more available material elsewhere. First and foremost, the toolkit aims to be as practicable as possible and help users determine, or rather, "interpret" human actions and behaviour during a safety event.
This web toolkit
This toolkit is intended to support a more just and fairer approach to faults and errors in highly complex environments. It is not yet another root cause analysis tool. It is not interested in the OUTCOMES of human behaviour. It does not ask you to judge, but it will attempt to help you interpret the intent of the behaviour of a person involved in a safety event (e.g. an incident or accident). The decision tree helps to pinpoint the type and causes of errors and mistakes made. it shows similar situations - and this is extremely useful!- from other industry so you can benchmark your interpretation against it. It also helps to recognize safe acts, and provides guidance as to how to use those to create an environment in which everybody feels safe to learn, and to improve, without running risks. You will be guided with texts about what potential consequences are suggested for the people involved in the safety event, as well as what appropriate follow up could be found for the supervisors or managers.
Who are you?
You are a manager, teamleader, safety officer, investigator or similar that works with a team of people to get a task done. This can vary from aviation, healthcare, rail transport, process industry, energy companies or similar. The basis is always that you want to make a good judgement of the safety situation in your daily work and above all prevent people from unjustifiably blamed for something there were just a part of.
You realize that people are your biggest asset in the company and blaming them for errors is the worst thing you can do. You understand that as long as you work with people, they will make mistakes. They will, willingly or unwillingly, violate rules that may or may not have been appropriate for the task at hand.
You are convinced that more safety can be gained with understanding why things happened and then get them solved, rather than going around punishing and blaming.
In four steps this toolkit can help you contribute to a more just and fair safety culture:
- Read the THEORY section to gain more insight into different types of safety behaviours.
- Use the home screen or the general purpose navigator to interpret the intent of the behaviour of a person during a safety event (e.g. an incident or accident). Select one of the behaviour classifications that you think is appropriate.
- Check out examples of this type of behaviour from different sectors, so you can 'calibrate' your interpretation with others. If you think your situation does not match the examples, go back and try a different classification.
- Read what could be an appropriate follow-up for the type of behaviour you have identified.
What is being taught here?
When a safety event occurs, like a mishap, accident or near accident, it is often obvious what went wrong. With hindsight, it is all too easy to point to a certain person that made a mistake, error of judgement, or violated rules. Quite often, this is not true. Nobody goes to work with the intention to make a mistake. But having blamed somebody for the event, the true failures in the system will not be laid bare, which are often wrong procedures for the task, ill-defined responsibilities or managerial flaws. The effect is that further safety improvement is no longer possible or even frustrated, particularly when events are being criminally prosecuted. The conditions for the safety event remain, until the dice are rolled again and another person finds himself in the same situation.
Although it is easy to explain what happened it is significantly more difficult to explain WHY it happened. Just saying "well, it was a bad person that did it" is simply too easy to be a real solution.
There is a clear and obvious relationship with the Just Culture movement that is going on in the world.
This toolkit should hopefully assist you in understanding the safety event that you experienced a little better. The toolkit is intended to guide you through the possible human behaviours that were at play. You will be able to use the toolkit for helping you select the right follow-up for human behaviour after a safety event.