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Safety and Justice/It's not that easy

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< Toolkit:Safety and Justice
Its not that simple.png
If the same type of error happens more often, regardless of the persons involved it really is time to look for the work circumstances. On the other hand, there could also be a case of "group-think" or a particular culture within the organisation that contributes to this situation.

What are you correcting

The most important thing you are correcting here is the fact that the organization has stopped learning. A one-time error is hard to avoid, but running into the same problem time and again is unnecessary and the solution is within the control of the organization itself. You want to find the pattern, and correct that.

If more people are making the same errors, first thing to do is check the circumstances of the work for clarity, distractions, etc. Assuming this is okay, the team could use refreshers on how to recognize circumstances that may lead to slips/lapses or are specially inviting mistakes. Also, check for shared thought patterns and beliefs that may lead to this situation. A culture of "Rules are there to be broken" for example.

How are you correcting

Find the pattern. This is not about an individual, but about the whole organization that leaves a pattern in place leading to known risks! Involve everybody by making it safe to look at their role in the whole process, asking the question "what is really going on here" and "what makes that time and again we get back into this situation".

There are also things that keep this pattern in place. That may be at the individual level ("I do not want to change") or at the organizational level ("Well, if we are going to change that it will required a significant investment in resources and I do not want to be the one that puts that on the agenda"). Be brave in putting the problems on the table!

The manager of this team should have recognized this situation and taken appropriate corrective actions. If not, manager’s abilities to find out these negative trends earlier need refresher training. How is the manager handling the team? Check the manager – workforce relationship and management style.

Explanation consequences
Now you are at the level of the Just Culture consequences that we are suggesting.

If you feel these consequences are not appropriate, maybe you could consider going back up the navigator and trying some other branches.

Substitution Test
The Substitution Test helps to assess how a peer would have been likely to deal with the situation.

Johnston (1995), a human factors specialist and an Aer Lingus training captain, has proposed the substitution test. When faced with an event in which the unsafe acts of a particular individual were clearly implicated, the judges should carry out the following thought experiment. Substitute for the person concerned someone coming from the same work area and possessing comparable qualifications and experience. Then ask: 'In the light of how the events unfolded and were perceived by those involved in real time, is it likely that this new individual would have behaved any differently?' If the answer is 'probably not' then, as Johnston (1996:34) put it, 'apportioning blame has no material role to play, other than to obscure systemic deficiencies and to blame one of the victims'. A useful variant on the substitution test is to ask of the individual's peers: 'Given the circumstances that prevailed at the time, could you be sure that you would not have committed the same or a similar type of unsafe act?' If the answer again is 'probably not', then blame and punishment are inappropriate.