Just Culture – from aspiration to reality - raes-hfg.com

1 just Culture from aspiration to reality Keven Baines Managing Director Baines Simmons Limited Baines Simmons Limited 2008. Background to this work The fragility of a just Culture - inconsistency of just Policy application is a common killer of a safety Culture Our experience of the real-world application of extant culpability models taught us that there is a pressing need for a: workable, straightforward toolset toolset which can be repeatedly and credibly applied by non-HF specialists toolset that does not require extensive training tool that minimises variability, ensures consistency and stands the test of perishable training Outcome The FAIR system (Flowchart Analysis of Investigation Results).

2 FAIR is free of charge Baines Simmons Limited 2009. The basis of FAIR . The best practice' elements of the two main academic (Reason/Hudson) in-use' models (C) Baines Simmons Limited 2009. Prof. James Reason - Culpability Model'. Further developed by QANTAS Airlines and Baines Simmons Limited Were the Pass substitution actions as Unauthorized *Knowingly test History of intended? No substance? No violating No Pass unsafe safe operating acts procedures Yes Yes Yes Fail Yes No Were procedures available, workable, No intelligible and correct? Deficiencies in Medical training &. condition? Yes No selection or inexperience Were the Evidence Situational Routine or consequences as of reckless, Violation - Normative Blameless Blameless intended optimising Under Common error but error or pressure to practice to corrective negligent get job ignore No Yes training or behaviour done Procedure counselling No Yes indicated System Possible Induced Yes error of Error Yes judgement Yes System Induced Substance Substance violation abuse without abuse with Possible mitigation mitigation reckless violation Sabotage Diminishing Malevolent culpability damage Substitution Test etc.

3 Question to peers: Given the circumstances, is it possible that you could have made the same or a similar error . *Knowingly means knew operating procedures exist but If answer yes then blame inappropriate. ignored/chose not to comply with them. The best people can make the worst mistakes. Safe Operating procedures are: Standard practices Company policy and procedures Maintenance manual procedures Prof. Patrick Hudson just Culture Model Did they follow Did they think Everyone does I thought it was I thought it was Description We can't follow Screw you. all procedures they were following It this way around better for the better for me Oh the procedure and I meant to do it and correct procedures here.

4 Company to do personally to we did that!? get the job done my way best practices? and practices? Don't you? the job that way cut a corner Normal Compliance Unintentional Routine violation Situational violation Optimizing Personal optimizing Reckless personal Exceptional Violation type violation violation violation optimization violation Awareness/. Understanding Get engaged Set standards Did we not expect Feel comfortable, Why didn't people Take active steps Examine processes Management -how much is this Examine hiring & How did we hire such situations But be aware, this realize this was a to reduce frequency This may be a real happening? retention Such a person? to arise? May be unusual Problem?

5 Of violation or norm improvement Can I let it continue? policies EHS-MS problem? Investigate and Investigate- Why is this not Set standards How did we let Did we train Supervision Investigate and raise awareness Must listen to being recognized? recognize that him stay here? people in how to Praise the worker apply standards of workforce Use processes to such people are Didn't we know react in unusual standards complaints legitimize variances In workforce In advance? circumstances? Report if they Workforce Get involved in Must report all Report possibility, Decide whether discover they have Did I/we use ALL. Feel satisfied aligning procedure such impossible raise before work you wish to Leave Company violated a resources?

6 To reality situations acquire competence work here procedure Active coaching of Second-level Did they follow First level First level Third-level Discipline Console the all, at all levels for Discipline all procedures None formal discipline formal discipline discipline worker condoning routine warning and counseling counseling dismissal violation letter or time off best practices? Counsel people to Counsel people to Management need Validate standards Praise the worker tell (workers) tell (workers). Coaching to examine the to see if rule We all need to Use as an example and and N/A N/A. quality of necessary, or look in the mirror For others listen (managers & listen (managers &. Procedures/ system ensure compliance supervisors) supervisors).

7 Flowchart Analysis of Investigation Results (FAIR ). Were *safe operating Were the consequences as Sabotage or reckless procedures knowingly ignored / Yes Yes intended? behaviour rules broken? No No Y Y Personal In the circumstances of the Did the actions benefit the optimising rule- Was the correct plan event, could the task have been individual? of action selected? Yes Error breaking done in accordance with safe*. operating procedures? No Organisational Did the actions benefit the Y. optimising rule- organization? breaking No No Mistake /. unintentional rule-breaking Was the situation outside Exceptional Yes normal operating procedures? rule-breaking No Situational rule-breaking Apply routine and substitution test at each outcome to determine most appropriate intervention actions Baines Simmons Limited 2009.

8 Flowchart Analysis of Investigation Results (FAIR ). Unintended Action Intended Action Intended Action The line in the sand Unintended Consequence Unintended Consequence Intended Consequence Error (slips and lapses) Unintentional Knowing rule- Sabotage rule-breaking breaking Skill-based Reckless behaviour Mistake Situational Memory or attentional failure Gross negligence Rule-based Organisational optimising Personal optimising Knowledge-based Exceptional 1 - Substitution test: Would someone else in the same situation have done the same thing? (if not, what is it about individual?). 2 - Routine test: Does this happen often to a) the individual or b) the organisation? 3 - Proportional punishment test: What safety value will punishment have?

9 4 - Intervention: What needs to happen to reduce likelihood of recurrence at a) an individual level and b) an organisational level? Increasing culpability Manage through improving performance influencing factors (PIFs) person, Manage through appropriate task, situation, environment disciplinary action Managing The Three Behaviours Normal Error At-Risk Behaviour Intentional Risk-Taking Manage through changes Manage through: Manage through: in the immediate system': Understanding our at- Disciplinary action Processes risk behaviours Procedures Removing incentives for at-risk behaviours Training Creating incentives for Design healthy behaviour Environment Increasing situational Move or manage the awareness person Baines Simmons Limited 2009.

10 Where does FAIR reside in your Error Management System? Further unsafe act'. information required Carry out Root Investigation *FAIR system Instigate Unwanted Precautionary Cause Investigation' Output - Event disciplinary action? See next page event/error or (using tools such as Review Team process MEDA, HFIT, PEAT, (ERT) convened near miss REDA) using trained investigators No Further action regarding person Non-Judgemental Decision Judgemental Baines Simmons Limited 2009. (developed) Substitution Testing This must be carried out by the Event Review Team (ERT) on at least three of the person's peers. The substitution test is designed to ascertain whether, in the circumstances, it is possible that another similarly skilled, trained and experienced individual would have done anything different.