This document discusses different approaches to handling mistakes and errors in organizations: 1) A blame culture focuses on concealing errors and avoiding responsibility. 2) A no-blame culture avoids personal responsibility and prevents organizational learning. 3) A just culture balances safety, accountability, and learning by distinguishing intentional violations from unintentional errors, and encouraging open reporting to improve the system.

1. Blame Culture, No-Blame Culture and Just CultureKeith Grint & Clare Holt

2. “The operator of an aircraft, the surgeon performing an operation, must all foresee that their acts might cause death; but we should not describe them as reckless unless the risk taken was unjustifiable.” Smith & Hogan, 1975. Criminal Law According to World Health Organization (WHO)….. You have 1 in 10 million chance of dying in a plane crash You have 1 in 300 chance of dying from a healthcare error in hospital (The Times , 22/7/11)

3. 3 What happens when it all goes pear-shaped?

4. CLASSIFICATION OF ERRORS BASIC ERROR TYPES Attentional failures Intrusion Omission Mistiming Etc. SLIP UNINTENDED ACTION Memory failures Forgetting Omission Place-losing LAPSE UNSAFE ACT Rule-based Misapplication of good rule Application of bad rule Knowledge-based Many variables Untested Process MISTAKE INTENDED ACTION Routine violations Exceptional violations Acts of sabotage VIOLATION Taken from ‘Human Error’, James Reason (1990, 2009), p207

5. CLASSIFICATION OF ERRORS BASIC ERROR TYPES Attentional failures Intrusion Omission Mistiming Etc. SLIP UNINTENDED ACTION Memory failures Forgetting Omission Place-losing LAPSE UNSAFE ACT Rule-based Misapplication of good rule Application of bad rule Knowledge-based Many variables Untested Process MISTAKE INTENDED ACTION Routine violations Exceptional violations Acts of sabotage VIOLATION Taken from ‘Human Error’, James Reason (1990, 2009), p207

6. BLAME CULTURE (1/2): The Sweep it under the carpet school of management You’ve made a mistake Will it show? YES Can you hide it? YES Conceal it before somebody else finds out NO NO Can you blame someone else, special circumstances or a difficult client? Get in first with your version of events YES Bury it NO NO Sit tight and hope the problem goes away Could an admission damage your career prospects? Problem avoided YES

7. BLAME CULTURE (2/2): The Sweep it under the carpet school of management You’ve made a mistake Will it show? YES Can you hide it? YES Conceal it before somebody else finds out NO NO Can you blame someone else, special circumstances or a difficult client? Get in first with your version of events YES Bury it NO Personal Responsibility Avoided; Organization Continues to Fail; no-one Seems to know why…. NO Sit tight and hope the problem goes away Could an admission damage your career prospects? YES

8. No-BLAME CULTURE (1): You’ve made a mistake Will it show? YES Don’t need to hide it It wasn’t your fault It was probably the fault of the system Admit it NO Ignore it Personal Responsibility Avoided; Organization Continues to Fail; no-one Seems to know why….

9. No-BLAME CULTURE (2): You’ve made another mistake Will it show? YES Don’t need to hide it It wasn’t your fault It was probably the fault of the system Admit it NO No Learning! Ignore it Personal Responsibility Avoided; Organization Continues to Fail; no-one Seems to know why….

10. JUST CULTURE: You’ve made a mistake Don’t need to hide it Could be partly your fault but it’s likely that other factors are also involved You have a responsibility to prevent it happening again Admit it Will it show? YES NO Report it through the appropriate channels Admit it Personal Responsibility Taken. Organization Continues to Improve –everyone knows why…. Investigated Organizational learning occurs Information fed back to individual as well as the organization

11. Just Culture: A Brief Theoretical Overview from ‘Accident’ Theory In the beginning.... Human Error (First Story Accounts) 2. Sequence of Events 3 . Systems (Second Story Accounts; tight/loose coupling icebergs & hard shell/soft shell + process/SOPs) a. Latent Failure/Swiss Cheese model b. Normal Accident c. Just Culture 11

12. 1. HUMAN ERROR (First Story Accounts – the initial assumption) Biggest personnel problem for US military: getting the right people in the right jobs – problem of selection – fixed through competency framework 1943 P-47s & B-17s keep crashing – wheels are retracted on landing instead of flaps Cannot be the planes – look at how robust they are – must be the people. B-17 After B-17G-80BO 43-38172 8th AF 398th BG 601st BS damaged on a bombing mission over Cologne, Germany, Must be HUMAN ERROR – So , what’s wrong with our pilots? B-17 Before 12

13. Alphonse Chapanis How come the P-47 pilots make same error but C-47s’ don’t? 13

14. 1. HUMAN ERROR P-47 Thunderbolt Flaps & Wheels 14

15. C-47/DC-3 1. HUMAN ERROR C-47s don’t have side by side wheel and flap controls with identical levers & coloured toggle switches 15

16. Alphonse Chapanis Mark wheel lever with a wheel & flap lever with a triangle – significant reduction in landing ‘accidents’ HUMAN ERROR is just one possible explanation: 1st story account It’s likely that such mistakes will recur because of the connection between the human and the system – 16 1. HUMAN ERROR

17. Folk Myth: systems are 100% reliable – as long as they are protected from human error Reification: a system is an objective, stable & predictable ‘thing’ - not a moving mass of stuff. Response: eliminate human error, especially in high risk organizations Consequence: system becomes more calcified/brittle – allows less, not more, learning 17 1. HUMAN ERROR

18. Hard Shell (Exogenous) V Soft Shell (Endogenous) organization Hard Shell – externally strong, process-driven but brittle system designed to prevent error Soft Shell – externally weak but flexible system: built in resilience via capacity to learn & rectify error 18 HARD SHELL - SOFT SHELL Is the safety system hard or soft – prevention or recovery?

19. 2. Sequence of events model (Heinrich, 1931) – domino run model Events preceding accident occur in linear fixed order with the accident being the last in sequence Solution: a sequence of barriers to reduce hazard, absorb energy & prevent accident Space Shuttle Columbia 2003: Piece of foam strikes wing on launch breaching thermal protection On re-entry superheated air melts wing which breaks off Solution: 19

20. 2. Sequence of events model (Heinrich, 1931) – domino run model Events preceding accident occur in linear fixed order with the accident being the last in sequence Solution: a sequence of barriers to reduce hazard, absorb energy & prevent accident Space Shuttle Columbia 2003: Piece of foam strikes wing on launch breaching thermal protection On re-entry superheated air melts wing which breaks off Solution: reinforce wing 20

21. Sequence of Events Model: the hindsight problem Safe Present The hindsight problem: View from investigator Critical Future “A map that shows only those forks in the road that we decided to take” Lubar, 1993: 1168 History from Things (Smithsonian Institute) 21

22. View from the decision-maker Future Present Future Future Future Future Future Future Future 22

23. 23 NietzscheanAnxiety over determining causation If we cannot determine cause then ‘problem’ is potentially irresolvable Scott Snook : accidental shootdown of US Blackhawks in Iraq There was ‘no bad guy… no smoking gun, no culprit.’ Wrong answer – find a cause Durkheim’s scapegoat 23 23

24. 2. Sequence of events model (Heinrich, 1931) – domino run model The hole in the wing was produced by not simply by debris but by holes in organizational decision-making 24

25. 25 3. Systems Approaches/ Second Stories

28. success & failure is a result of how sharp end practitioners cope with complexity & how their actions are shaped by resources & constraints of those at the blunt end27

29. Bricoleurs: (Levi Strauss) people who achieve success by stitching together whatever is at hand, whatever needs stitching together to ensure practical success. Bricoleurs & the possibility of rescue: First-Responders to the flooding in New Orleans Kroll-Smith et al, (2007) Journal of Public Management & Social Policy (Fall) The CPR (Cardiopulmonary resuscitation) paradox: 5 trainee + 1 experienced paramedics filmed using CPR Film shown to three groups: who is the experienced one? Experienced paramedics get it right 90% Students right 50% Instructors right 30% Why?

30. Bricoleurs & the possibility of rescue: First-Responders to the flooding in New Orleans Kroll-Smith et al, (2007) Journal of Public Management & Social Policy (Fall) The CPR (Cardiopulmonary resuscitation) paradox: 5 trainee + 1 experienced paramedics filmed using CPR Film shown to three groups: who is the experienced one? Experienced paramedics get it right 90% Students right 50% Instructors right 30% Why? Instructors follow training protocols; experienced paramedics know that the protocols don’t always work Training V Education? Bricoleurs can be undermined by over relying on protocols? First responders in New Orleans were left to their own devices

31. St Claude Bridge People sheltered on the bridge but the water rose rapidly Police officer went to National Guard base near the bridge and asked a colonel for the buses to rescue the people Colonel refused but said he would ask his general – but wasn’t sure where he was ... No buses left the depot

32. One ambulance driver carried 42 people in one go Police officer commandeered (stole) a refrigerator truck siphoned (stole) diesel from abandoned vehicles to keep it running to feed 100 people for days

34. To understand failure you must first understand success – how people at sharp end learn & adapt to create safety or success in world fraught with hazards, trade-offs & multiple goals 32

35. Iceberg model: 1 accident 10 incidents 30 near misses 600 unsafe acts 33 Reduce the unsafe acts to reduce the accidents

36. But US air data suggests the airlines with the most incidents & near misses have the lowest # accidents 30,000 near-miss/trivial reports per annum in US aviation Almost no catastrophic crashes reported. The ability to learn is critical to safety because you cannot build a completely safe system passengers have to fly 19,000 years to die in place crash 34

37. 3a. Latent Failure Model – Swiss Cheese Model (Reason, 1990) Some of the factors that contribute to disaster are latent – present before the disaster - ‘Hidden Pathogens’ (Reason) Active Failures: unsafe acts – people at sharp end – errors quickly apparent Latent Failures:features that lay dormant & only become evident when they combine and are triggered – people at the blunt end ‘People at the sharp end – operators – are not usually the cause of the accident but the inheritors of system defects created by poor design, incorrect installation, faulty maintenance & bad management decision’ (Reason, 1990: 173 Human Error) Safety critical systems have a series of barriers to prevent/limit/absorb danger But each barrier has holes in it – imperfections – when all the holes line up and are penetrated – disaster occurs 35

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39. 37 Build an error-tolerant system with long recovery interval If the elimination of error is impossible must build system that enhances error recovery How good is the system at recognizing & responding to disturbances?

40. 3b. Normal accident theory (Perrow) Multiple safety systems add complexity and increase opacity – When things start to go wrong it’s difficult to see or act appropriately Systems involved - not a single or set of component failures, but the unanticipated interaction of a multitude of events in a complex system Accidents are not unusual events but normal events given the complexity & tight coupling of the system 38

41. 3c What is meant by ‘Just’?Dekker (2007) Balancing safety with accountability JUST CULTURE Satisfies the demands for accountability Contributes to learning and improvement Not punishing for ‘unintended’ errors which are part of the professional role of the individual, BUT intentional violations and destruction, are not tolerated 39

42. What is Just? What isn’t Just? Where do you draw the line? Who draws the line? What is the line? ‘It’s not obvious, but it needs to a be a judgement by the organisation looking at ‘politics, power and populism.’ (Dekker, 2011) i.e. individuals should be included in the decision! There needs to be some trust to encourage honesty, but what is acceptable/unacceptable needs to be clear Some organisations are subject to regulatory bodies, some set up their own safety boards and ethics committees 40 Violation Intentional Slip, lapse Unintentional

43. Safety Culture = Just + Open Violations can be linked to culture A ‘No Blame’ culture is neither Feasible, Desirable, nor Accountability -free You need to look ahead to improve (accountability), and not blame the past. To encourage a ‘safety culture’ and hold individuals accountable, they must be given an appropriate level of discretion – ‘a culture of balance’ 41 I’ll get away with it! Everyone does it, they’ll just turn a blind eye.

44. OPEN-reporting Openness in reporting is providing the environment for individuals to report the trivial near-misses These are what can cascade into latent system failures that fester and can have catastrophic consequences! Front-line professionals are best used to help with future prevention – this can be hindered if they are treated like a criminal! 42

46. Easily submitted, with some immunity

47. Needs to be seen to be actioned - confidence

48. Lessons learned (training, change in SOP, etc)

49. Actions and lessons disseminated (if possible across an industry!)43

50. Things to bear in mind………… Health care, aviation, petrochemical, nuclear professionals, etc. all have a Criminalization of an unintended error can hamper a safe & just culture – this only encourages people to ‘hide’ their mistake(s) ‘ ‘Dispensing mistakes [in healthcare] happen. And even with the introduction of robots and SOPs, the Utopian ideal of a world without errors is closer to fantasy than reality.’ 44 STRONG SAFETY ETHIC Chapman, 2009 ‘A criminal mistake?’

51. Conclusions: Stop looking for psychological error mechanisms – 1st story accounts stop blaming HUMAN ERROR Systematic features of the environment can trigger predictable actions that lead to ‘error’ Safety is less a feature of the system and better understood as being created by people in complex systems Are systems safe & therefore need protecting from unreliable humans? Or does the elimination of human ‘unreliability’ make the system more brittle so that the sources of resilience are eliminated? ‘the enemy of safety is not the human: it is complexity’ Woods et al, (2010:1) Behind Human Error (Ashgate) 45

52. A Safety, Just and Learning culture can be strived towards but rarely attained It is the process that is important! 46