When we think about just culture, we usually think about accidents and incidents, associated ‘honest mistakes’ and ‘negligence’ (by whatever name), as well as official responses to these, at company and judicial level. The notion of just culture is driven partly by fear; fear of being judged and blamed, especially fear of being blamed unfairly. The fear is felt most strongly by operational staff, who are at the sharp end of organisations and have sometimes faced disciplinary or legal action for their parts in accidents. This issue was discussed recently at a conference on just culture and the judiciary. The keynote speaker was Martin Bromiley, who talked about just culture in healthcare in the UK (Bromiley, 2016a). He and others raised the issue, both formally and informally, that judgements do not just come from the judiciary. After many hundreds of hours spent talking to thousands of people in interviews and focus groups – from operational staff to Board members and judiciary – about about aspects of safety and fairness, the question that came to my mind was “Who are people really afraid of?”…and why?
Most of my time has been spent talking to operational staff (e.g., air traffic controllers and technicians, and others in different industries). Since they do the sharp-end operational work, it is important to understand from them what and how they think, and to understand how things really work at the sharp end. But I have also spent much time talking to other stakeholders: specialist and support staff, middle managers, senior managers/directors, national judiciary, and policy makers. Whenever talk comes to issues of fairness or justice, there is usually a ‘them and us’ tone to discussions. To front-line staff, it’s the actions of ‘us’, and the responses of ‘them’.
But who is ‘them’ really? The ultimate judge of whether an action constitutes gross negligence is the judiciary. Of course, people have been prosecuted for gross negligence, such as flying while drunk. People have sometimes been prosecuted and even convicted for what many would now term ‘honest mistakes’, perhaps actions or decisions that many others in the same situation, with similar training or experience could have made, at some time or other. But in aviation, these cases are relatively rare. In the past 40 years, the numbers of pilots, engineers and air traffic controllers convicted is low. Prominent cases involving commercial flights include: Zagreb BA476 & JP550 (1976), Athens SWR213 (1979), Mt Crezzoin ATI460 (1987), Habsheim AF296 (1988), London Heathrow BA012 (1989), Schipol DAL039 (1998), Yaizu JAL907 (2001), Linate MD87 & C525 (2001), Uberlingen (2003), Palermo TUI1533 (2005), Athens HCY522 (2005), and Mato Grosso GLO1907 & N600XL (2006) (Smoker and Baumgartner, 2016). Following other accidents, individuals have faced charges, which were later dropped, and others have been acquitted. In aviation, relatively few judgments are made by the judiciary against front-line staff, especially for accidents where there is no sign of reckless or grossly negligent behaviour (what constitutes ‘gross negligence’ is a matter of legal judgment and also varies between states; some do not differentiate between ‘negligence’ and ‘gross negligence’, while other countries have special exceptions for some professionals for ‘minor’ cases of ‘negligence’).
Indeed, people in air traffic management rarely mention the judiciary as a source of significant concern in discussions about just culture in a normal work setting. Even when asked directly, many people have not given prosecutors and judges much thought. People are often unsure what would happen if they got caught up in a prosecution. This is not to say the role of the judiciary is unimportant or that legal and other support in the case of a prosecution is unimportant; it is very important. The judgement of the judiciary is just not something that seems to be weigh heavily on people’s minds when the topic of ‘just culture’ arises in discussions about safety – at least in air traffic management. This would be different for other professionals in transportation (e.g., pilots and some train drivers) who travel through different judiciaries, and for healthcare professionals, who face complaints from patients and are arguably far more exposed.
People in air traffic management also do not often talk about the role of senior management with respect to just culture. The Board is responsible for policy (including just culture policy) but does not frequently make judgements about the performance of individuals. It is not the judgement of the CEO whom people seem to fear, nor usually the Safety Director (where one exists). In some cases, the HR Director may be a person of concern, but only if judgements about performance are passed to them from someone else, for instance a Director of Operations. Directors of Operations usually come from an operational background themselves (though they rarely remain operational, partly due to lack of time). But the Director of Operations is usually only of concern if judgements about performance are passed to him or her from someone else, for instance via an investigation.
Indeed, the main focus of discussion with operational staff about just culture usually concerns investigations and investigators. Being blamed in the context of a safety investigation is contrary to the purpose of a safety investigation, partly because it is deathly for an occurrence reporting system, and for any subsequent investigations and learning. Trust is built up slowly between people, especially in organisations made up of silos, but it is destroyed in an instant. People immediately lose trust in safety processes and practitioners when they perceive that they are blamed for events in the context of a safety investigation. Again, investigators are typically from an operational background. Some remain operational, while others do not (for instance due to lack of time, or for reasons of competency, age, or health), and tend to become more distanced from the operational work.
Quite often, what is really interesting about discussions concerning safety and justice is what is not said openly, when it is clear that something is being omitted. These are the taboo subjects. Sometimes, people indicate that there is a problem and that they will not discuss it in a group, but will mention these problems in private (interviews), in breaks, and as they are about to leave the room (door handle moments). Just culture among colleagues is one of these issues. What people fear most of all is not the judgement of those who are most distant from the work, whose judgements are relatively rare. What people fear is the judgement of those closest to the work – their co-workers. Except in the most open of cultures (rare exceptions, such as Scandinavian countries), usually people will avoid discussing this openly in a group setting. People fear raising the issue of judgement and blame by colleagues because they fear being judged and blamed for raising the issue. A doctor friend of mine who is the head of a department in a French hospital once told me about his attempt to discuss just culture with his colleagues (the doctor is not French). He decided to recount a story of an ‘honest mistake’ in a messy situation, of the sort that is typical of healthcare. After telling the story, his colleagues pounced on him, pointing out what he did wrong and what he should have done. It was the last time he tried such an exercise. This experience is far from unique. Indeed, in healthcare, clinicians seem to fear most the judgement of other clinicians (Bromiley, 2016a). Human beings tend to have a strong need to belong and a strong need for group identity. Discussing internal threats to that group identity can itself seem threatening.
The judgements of those closest to us are of most concern to us for two key reasons. First, we have to continue working with or alongside these people from one day to the next. Strained relations make for an unpleasant working life. Second, people in the same sort of position have an advantage that is not present in those who are far removed from the work (e.g., senior management of the judiciary). The advantage is this: our colleagues and co-workers know how the work is done and have an imagination about how they think they would have done the work (i.e., better) (Shorrock, 2016). They have confidence that this imagination is what would actually happen, but this is far from the case (Bromiley, 2016b). While a coworker’s Work-as-Imagined is not another worker’s Work-as-Done, it is closer than Work-as-Imagined in the minds of anyone else. Co-worker judgements therefore hit closer to home. Co-workers can point out our errors in the same way that we can point out theirs. They know the work and may do it themselves, so their judgements carry most weight.
It is not just operational staff, of course. It is all of us. Think about how you drive. If you are like most people, you probably spend much more time judging others’ driving (including, or especially, your partner’s) than you spend thinking about how you are driving. In any case, we think our driving is better than average (Roy and Liersch, 2014). Our self-serving bias is strong.
We are then, as groups, our own worst enemies. We demand fairness from others (especially other professionals – out-groups), but continue unfairly to blame others. At this point, you might complain that, “Judgement by colleagues is less important than judgement by a judge!“. It is probably true that, when it comes to justice, an individual judgement by a judge (especially a conviction) is more important than a judgement by a colleague. But to assume greater importance for judiciary judgements overall would be to captured by the déformation professionelle of traditional ways of thinking about safety (Safety-I), that rare adverse events are much more important than everyday work, and therefore we should focus only on accidents. Front-line staff naturally seem to accept that focusing only on accidents in order to understand a lack of accidents doesn’t make sense. Conversely, front-line staff naturally seem to accept that to improve safety, you have to focus on everyday work, not only accidents (past or future). It follows then, that to improve fairness or justice, we have to focus on everyday judgements, not just rare judgements of the sort that arise from judicial investigations (or even safety investigations).
Even accepting that everyday judgements are high frequency, it is a serious mistake to think they are of low consequence. When we think back to the real impact of co-worker judgements about us and our performance, we find that their impact can be enormous. Being judged or blamed for our individual part in routine work in a messy situation and complex system, when outcomes are not as planned, leads to a number of negative thoughts and emotions, including resentment, anger, worry, and preoccupation. Being judged can lead to lost sleep, damaged self image, mental and physical health problems, interpersonal problems and strained or ruined relationships. Being judged can lead to company disciplinary proceedings and even legal action (defamation; slander, libel). On an operational level, blame by colleagues can lead to non-cooperation, such as the withholding of operationally relevant information within or between teams. This, in turn, becomes a safety issue.
Demanding justice from an out-group while ourselves denying it to others in our in-group is understandable. Constructing a common external threat (out-group derogation) seems to help internal solidarity. But when the real threat is internal, then this is a kind of hypocrisy that we should address. And while front-line staff are the most vocal supporters of just culture, for good reason, perhaps the judiciary are the unsung champions of just culture. The judiciary spends weeks and months collecting factual and other information, reviewing and discussing the information, and deliberating upon that information, before forming judgments – all for an event that may have lasted minutes. This difference between the time frame for Work-as-Done versus Work-as-Judged is perhaps one reason why we focus on the judgments formed in criminal and safety investigations, and this is a fair point. We think that such judgments should never be unjust, because there is sufficient time to make a just judgment (while ignoring the constraints of the national legal systems and penal codes). Our everyday judgements, on the other hand, are formed and expressed in haste, in seconds or minutes – a similar timeframe to that of the work being judged.
So what to do? Perhaps the most important actions we can and should take concern us, not them. Addressing our frequent, everyday blaming and shaming judgements in response to outcomes-not-as-planned will likely have the most impact on human wellbeing and safety.
Be mindful of your personal reaction to failure
- Reflect on your initial internal reactions. How did you react emotionally to what you observed or heard? What feelings did you experience? Your immediate internal reaction may have been anger or fear, for example. People who are involved and uninvolved will tend to have different internal reactions. Those directly involved, and who could be judged, may be more likely to experience fear. Those uninvolved, or involved but unlikely to be judged, may be more likely to experience anger, or perhaps sympathy (via identification).
- Reflect on your judgements and evaluations. Following these reactions and feelings, what did you think about all of this? How did you interpret and evaluate what happened at the time? When considering your involvement in an adverse event or unwanted situation, you may have judged yourself harshly. Perhaps you felt disappointed in yourself, even doubted your competency. When evaluating another person’s involvement, consider whether your focus is on the individual or the situation and system, and to what extent you are judging and blaming an individual (whether or not this is expressed). The focus should not be on part of the picture, but the whole picture. At this stage, be mindful of the outcome bias. Knowing the outcome of an event changes the way that you think about the actions and decisions that took place in the run-up to that outcome. Experimental studies have shown repeatedly that the exact same performance will be judged differently depending on the outcome. This is confirmed in our everyday experience. Often, what makes performance ‘bad’ is not the performance itself, but the outcome (e.g., accident). Had there been no accident, the performance would often be judged as normal (‘uneventful’), perhaps even rather efficient or effective. Be mindful also of the fundamental attribution error. We have a tendency to from dispositional rather than situational explanations for others’ behaviour. We are prone to blame, but this can be overcome with education, at least at the stage of judgement and evaluation (if not initial internal reaction). If you are involved in investigation, then your responsibility to reflect on your judgements and evaluations is greater still.
Be mindful of your interpersonal reaction to failure
- Empathise. Empathise with others to understand their local rationality. If we really want a just culture, then we have to empathise with others and understand why what they did made sense to them at the time. Try to understand the background situation and the person’s world via ‘person empathy’ or ‘background empathy’. Also try to develop a moment-by moment empathy for the person’s experience, cognitively, emotionally, and physically, using ‘process empathy‘. Seek not to judge, but at least to understand. This is an interpersonal activity because it will tend to involve talking to people. Empathy is not a solo activity. It has to be experienced by the other person. Carl Rogers (1956) noted that, “Unless some communication of these attitudes has been achieved, then such attitudes do not exist in the relationship as far as the client is concerned.”
- Consider needs. Based on this empathic understanding, think about what others need, and what would get in the way of their needs being met. How would they like to be treated, helped or supported? It might be helpful to ask these questions of yourself, thinking back to a situation where you were in a similar position, and when your needs were met or not met. But remember that your needs are not theirs.
- Apologise. We all get it wrong and judge or blame others unfairly from time to time in everyday life, including at work. We cannot stop others from doing this, and we will sometimes relapse into blame ourselves. But we can keep our side of the street clean when we do slip up, by apologising. Some people find this easier than others, but it requires little effort other than swallowing one’s pride. Express how you jumped to judgement without thinking it through or thinking about what they need. Consider how the above might be applied. There is little more restorative in a relationship than an honest and unreserved apology, and perhaps an offer to make amends.
So to answer the question, “Just culture: Who do we fear?”, it is the judgement of those close to us – in or from the same world – that we fear the most. It is also those close to us who we can help the most.
Bromiley, M. (2016a). Healthcare’s just culture journey: A long and winding road. Just Culture and the Judiciary. EUROCONTROL Experience Sharing Enhanced SMS ES2-WS04-16 seminar, “Just culture across industries: Learning from each other”, Lisbon, 22-23 November 2016.
Bromiley, M. (2016b). Foreword. In, S. Shorrock and C. Williams (Eds.), Human Factors and Ergonomics in Practice: Improving System Performance and Human Well-being in the Real World. CRC Press.
Smoker, A. and Baumgartner, M. (2016). IFATCA – Experience with accused individuals. Just Culture and the Judiciary. EUROCONTROL Experience Sharing Enhanced SMS ES2-WS04-16 seminar, “Just culture across industries: Learning from each other”, Lisbon, 22-23 November 2016.
Rogers, C. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103.
Roy, M. M., Liersch, M. J. (2014). I am a better driver than you think: examining self-enhancement for driving ability. Journal of Applied Social Psychology, 43(8), 1648–1659. DOI: 10.1111/jasp.12117
Shorrock, S. (2016). Work-as-Imagined, Work-as-Done, and Just culture. EUROCONTROL Experience Sharing Enhanced SMS ES2-WS04-16 seminar, “Just culture across industries: Learning from each other”, Lisbon, 22-23 November 2016.
Safety-II and Just Culture: Where Now?
Exploring experiences using Schein’s cycle
Systems Thinking for Safety: From A&E to ATC
Systems Thinking for Safety: Ten Principles
Occupational Overuse Syndrome – Human Error Variant (OOS-HEV)
Human Factors at the Fringe: My Eyes Went Dark
This post was inspired by several conversations and presentations at the conference mentioned in the post.
Note: I have tried to use the British spelling of ‘judgement’ for the everyday use of the term, and the British legal spelling (and routine American English spelling) ‘judgment’ for legal judgments. I have probably not achieved this aim.
Great post Steve and very timely given that I am trying to get divers in my organisation to talk about their failures, mistakes and errors but there is some reticence, some of which appears to be about litigation. However, I perceive the greatest fear is the one you cite – fear of social retribution from colleagues. In a sport where instructors are often placed on pedestals because of the time and effort required to get there, they fear criticism. Further, because there are no coherent standards in terms of performance or error (incident) then, as you point out, what is ‘wrong’ for one person might be acceptable for others – who is ‘right’.
Interesting piece Steven. I don’t fully agree with your comment “Some remain operational, while others do not (for instance due to lack of time, or for reasons of competency, age, or health)” it seems to suggest that people in investigator roles are there only because they are not fit for operational work. Some may well find themselves in such positions due to these reasons such as following an injury at work but in my experience people in these roles are genuinely interested in applying their knowledge of operational/clinical settings to improve conditions. There are system issues at play here too. These roles are usually responsible for large sites or numbers of services; we physically separate them from the “gemba”. In rural health this separation is further amplified by the tyranny of distance often limiting contact with the frontline to telephone or at best VC. Better models may include training frontline staff in incident investigation and the system supporting them to lead or be involved in incident investigations.
Thanks Wendy. I should clarify. This observation is in the context of air traffic management throughout Europe, where safety investigator roles are either part time (less common due to demands of the role and lack of operational staff) or full time, which leaves insufficient time to stay operational to stay competent (which can be harder as one gets older). Quite often, people do take on the role when the demands of shift work or other medical issues become too much. That’s very normal across Europe. I can’t really comment on healthcare investigation as I don’t know enough investigators, and I imagined to be more part time.