JUST CULTURE

Published: January 1, 2019

The concept of Safety Culture and its benefits for shipping companies is widely reported and well known. In 2013, the International Chamber of Shipping[1] defined such a culture as being represented by the “Values and practices that management and personnel share to ensure that risks are always minimized and mitigated to the greatest degree possible.” In essence, this translates to safety values being an central part of everything that a company and its employees do. In particular, the commitment to safety as the highest priority should be embedded throughout the entire organisation.

It is accepted that a key element of an effective Safety Culture is in fact the successful integration of a number of other ‘cultures’ within an organisation[2]. These include a Reporting Culture, where concerns and incidents are able to be reported freely and openly; an Informed Culture, where the reported incident data is collected, analysed and actively disseminated; and a Learning Culture. For the latter, the company strives to learn from previous events and improve its performance by addressing the lessons.

However, fundamental to all of this is the principle of “Just Culture”[3] [4]. This represents a shift from the previously widespread view that someone should always be held accountable in the aftermath of an accident, the so-called “Blame Culture” – this creates a “culture of punishment”, with the underlying assumption that the threat of being reprimanded, or at worst, being dismissed, would motivate individuals’ behaviour sufficiently to maintain safety. However, the problem with this latter approach is that the ‘fear’ of disciplinary action often stifles the reporting of accidents and ‘near miss’ incidents[5] as well as the willingness of people to openly assist with investigations, irrespective of the likely cause. Therefore the opportunity to learn invaluable lessons and improve safety processes as a whole is diminished, if not lost.

To counter this, the term “No-Blame Culture” is often referred to, However, in reality this is neither desirable nor feasible, as such an approach fails to account for intolerable behaviour, for example, gross negligence or a wilful violation of a procedure.

A “Just Culture” therefore addresses these concerns by clearly defining a policy whereby employees are encouraged to report accidents or incidents without fear of retribution unless their behaviour is unacceptable; this could include acting recklessly or taking deliberate and unjustifiable risks. The policy should clearly set out the expectations for adherence to company procedures and provide a context for enforcing them. It should also recognise behaviours that exceed company expectations, as well as those that may have dipped below an acceptable level, but might not be the fault of the employee.

A key requirement is that an organisation’s definition and implementation of “Just Culture” is available and accessible by all employees. This should in particular define what constitutes concepts such as “negligence”, “acceptable” and “unacceptable” behaviour following an incident or unsafe act, and how these will be investigated and dealt with. It is important that the principles should also be applicable to both ship and shore personnel.

Many organisations find it helpful to develop a “decision tree” to support their “Just Culture” policy; this can be extremely helpful to determine the level of, or lack of, culpability following an unsafe act. Flow charts[6] can also be created providing alternative “decision trees”, which can be adapted to suit an organisation’s particular needs. Having such a process mapped is really valuable in order to ensure that all employees are aware of the procedures for determining the degree of fault and the expected follow-up actions by the company.

Effective communication of the process within the organisation is important and this should be supported by training and guidance for both ship and shoreside personnel. Ideally, a “Champion” or “Owner” of the “Just Culture” process should be appointed in an organisation as the main focus and driver of the system.

The success of the process in particular relies on an atmosphere of trust among all personnel in the organisation and therefore needs to be implemented consistently and as far as possible, transparently. Key to this is the need to try to embed changes to existing attitudes and behaviours, for example, by encouraging or possibly even rewarding the reporting of incidents and other essential safety-related information. For example, by focussing on the positive consequences of reporting, rather than just looking to blame individuals, an effective “Reporting Culture” can be cultivated. Clearly this requires commitment throughout an organisation, in particular from the management’s commitment to safety and promotion of the “Just Culture”, as well as the active involvement of employees in the decision making and problem solving process.

An effective internal incident reporting system is also a crucial element of the process. This should be clear, open, anonymous, confidential and preferably managed with some degree of independence from other functions within the company. For example, consideration should be given to whether internal investigations will be conducted by a single department, or by different departments with differing investigation objectives. Some thought should ideally also be given to the incident reporting forms/templates and what information is required to be provided on these. The reporting/investigation process should also have clear outputs in terms of anonymised final reports with lessons learnt; this is essential to help demonstrate the value of reporting accidents and near misses to all employees.

Other stakeholders within an organisation need to be involved in the implementation of a “Just Culture” process, such as Human Resources (HR) and the Legal department, who will both need to ensure that their and any statutory obligations are still met. For example, does the HR “Disciplinary” process align with the overall “Just Culture” policy? This also raises the important issue of which person(s) within an organisation will be involved in deciding culpability following any “unsafe act”, e.g. this will likely be a team consisting of stakeholders from departments such as Health, Safety, Quality and Environment (HSQE), Management, HR and Legal.

The journey to developing a “Just Culture” can pose many difficult challenges for companies. However, the successful integration of this approach is considered an essential element of an effective, high performance safety critical organisation. By clearly defining the company’s policy for categorising and dealing with errors and unsafe acts in a fair and just manner, the benefits of enhanced reporting and transparency can reap significant advantages in terms of safety performance and efficient operations.

[1] ICS (2013), Implementing an Effective Safety Culture – Basic Advice for Shipping Companies and Seafarers, at: http://www.ics-shipping.org/docs/default-source/resources/safety-security-and-operations/implementing-an-effective-safety-culture.pdf?sfvrsn=8

[2] Reason, J (1997), Managing the Risk of Organizational Accidents, Farnham, Ashgate.

[3] Dekker, S (2016), Just Culture – Restoring Trust and Accountability in Your Organization, 3rd Edition, Burlington, Ashgate.

[4] UK Maritime & Coastguard Agency (MCA), Improving Safety and Organisational Performance Through A Just Culture, at: https://www.gov.uk/government/publications/a-just-culture-improving-safety-and-organisational-performance.

[5] IMO MSC-MEPC.7/Circ.7 – Guidance on Near-Miss Reporting, 10 October 2008.

[6] Hudson et al (2008), Meeting Expectations: A New Model for a Just and Fair Culture, Nice, Society of Petroleum Engineers, Ref: SPE 111977.

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