1. 1
MAKE JUST CULTURE
JUST YOUR CULTURE
It’s not what we believe, it’s what we do, that defines
our culture.
Dan Barker
Chief Architect - Archer
@barkerd427

2. 2
Background
A just culture is a culture of trust, learning and
accountability. - Sidney Dekker
@barkerd427

3. 3
Retributive vs Restorative
▪ Retributive
− What happened and who did it?
− Who should have stopped this?
− Blaming
▪ Restorative
− What needs exist?
− Who’s going to be accountable
− Learning
@barkerd427

5. 5

6. How Complex
Systems Fail
@barkerd427

7. Always in a state of
failure
How Complex Systems Fail
@barkerd427

8. There is no
“root cause”
How Complex Systems Fail
@barkerd427

9. Change creates
new failure modes
How Complex Systems Fail
@barkerd427

10. All actions are
gambles
How Complex Systems Fail
@barkerd427

11. Humans are the
solution
How Complex Systems Fail
@barkerd427

12. 12
“Safety is not the
absence of accidents.
Safety is the presence of
defenses”
Todd Conklin
@barkerd427

13. 13
5 Components of Mindfulness
▪ A constant concern about the possibility of failure
▪ Deference to expertise regardless of rank or status
▪ An ability to adapt when the unexpected occurs
▪ An ability to both concentrate on a specific task
while having a sense of the bigger picture
▪ An ability to alter and flatten hierarchy as best fits
the situation
@barkerd427

14. 14
“Start where you are. Use
what you have. Do what
you can.”
Arthur Ashe
@barkerd427

15. Change your
language
@barkerd427

16. I should have -> I
did x and expected
y, but saw z
@barkerd427

17. Blameless
Postmortems
@barkerd427

18. Timeline,
Just the Facts,
Learning
@barkerd427

19. Feedback
@barkerd427

20. Information
Transparency
@barkerd427

21. Asynchronous
Decisions
@barkerd427

22. Collaboration Tools
@barkerd427

23. Record Meetings
@barkerd427

24. Empower Others to
Learn
@barkerd427

25. How Complex
Systems Fail,
Westrum Model,
Just Culture
@barkerd427

26. Role Rotations
@barkerd427

27. Etsy Mixer
@barkerd427

28. Cross-functional
Goals
@barkerd427

29. Don’t Blame When
Failure Occurs
@barkerd427

30. Where will you fail?
@barkerd427

31. Patience
@barkerd427

32. Grace
@barkerd427

33. If you can’t change
your org, then
change your org.
@barkerd427

34. 34
References
▪ http://sidneydekker.com/wp-content/uploads/2018/12/RestorativeJustCultureC
hecklist.pdf
▪ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1765804/pdf/v013p0ii22.pdf
▪ https://web.mit.edu/2.75/resources/random/How%20Complex%20Systems%20
Fail.pdf
▪ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955339/
@barkerd427

35. 35
Dan Barker
dan@danbarker.codes
danbarker.codes
dan.barker@rsa.com
rsa.com
@barkerd427

37. 37
Why?
▪ Open communication and
transparency decreases litigation
▪ Aviation safety record
▪ Improve outcomes as a byproduct
▪ Potentially increase output
▪ Happier team members
@barkerd427