Just Culture Manifesto
From SKYbrary Wiki
"Just Culture" is a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.”
Organisations are run by people. In tens of industries – transportation, healthcare, energy, internet, and more – thousands of occupations, and millions of organisations around the world, it is people who make sure that things normally go well. And they nearly always do.
But sometimes, things go wrong. Despite our best efforts, incidents, accidents and other unwanted events happen. Following such events, there is a need for support and fairness for those involved and affected, and learning for organisation, industry and society as whole. In the absence of intentional wrongdoing or gross negligence, these obligations should not be threatened by adverse responses either by organisations or States.
The goals of this Just Culture Manifesto are to:
- articulate a vision of just culture that connects with people from all industrial sectors, around the world;
- speak to people in all roles – front line, support, specialists, management, both in private industry, government organisations and departments, and the justice system;
- provide a framework for other people to advance this vision of just culture.
As referred to in the JC definition, only a very small proportion of human actions is criminally relevant (criminal behaviour, such as substance abuse or misuse, grossly negligent behaviour, intention to do harm, sabotage, etc.). For the main part people go to work to do a good job; nobody goes to work to be involved in an incident or accident.
We have distilled five commitments that we believe are critical for Just Culture and the need to balance and the administration of justice.
- Ensure freedom to work, speak up and report without fear: People at work should feel free to work, speak up and report harmful situations, conditions, events, incidents or accidents without fear of unfair, unjust or unreasonable blame or punishment. Unfair, unjust or unreasonable blame or punishment does not motivate people to do a good job, nor to avoid ‘human error’. Instead, it reduces cooperation, trust and reporting, prevents innovation, and adversely affects healthy judgements about risks that are part of everyday work. Rather than making people afraid, organisations we all need to contribute to an environment where people can work and provide essential safety-related information to improve how the organisation works. While we aim for free and open reporting, people who report must be confident that their identity, or the identity of any person implicated, will not be disclosed without their permission or unless required by law – at any stage of the reporting, investigating and learning process.
- Support people involved in incidents or accidents: The organisation must support people who are involved in or affected by accidents. This is the first priority after an unwanted event. Accidents can be traumatic experiences for all involved. People may be distressed or injured, physically or psychologically. Support for people is therefore the first priority after an unwanted event. While adverse events such as accidents are uncomfortable and often distressing experience, the learning process should not be. Safety investigations and organisational learning activities concerning unwanted events should – as far as possible – be positive experiences for all involved, improving the design of the system, helping individuals, teams and the organisation to grow and become more resilient, and repairing – as far as possible –any damage done.
- Don’t accept unacceptable behaviour. Gross negligence and wilful misconduct are very rare, but cannot be not tolerated. The above commitments do not mean that ‘anything goes’. There must be constant discussion about the right professional behaviour and the consequences when professional boundaries are crossed. And nothing should prevent criminal prosecutions in the event of intentional wrongdoing or gross negligence; this is a matter for the judiciary.
- Take a systems perspective: Safety must be considered in the context of the overall system, not isolated individuals, parts, events or outcomes. The system is the main influence on performance. The system comprises human, technical, informational, temporal, social, political, economic and organisational components. These include goals and targets, demand, resources, constraints, incentives and reward systems, measures, work organisation, the work environment, and so on. The focus of the investigation and improvement will normally be on these system elements, and how they interact.
- Design systems that make it easy to do the right things: Improving safety means designing ways of working that make it easy to do the right thing and hard to do the wrong thing. This design process should be a collaborative and constructive that empowers those involved and affected as co-designers to help improve the system.
These commitments will not come to life on their own. People need to commit to them and make them a reality in organisation and societies. We are committed. We hope you are too.
We invite all who support the principles in this Manifesto to join us, and to help make Just Culture a reality in all countries, industries, and occupations.
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Yes, I want to join as well! Sign my name to this list.
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