Just Culture

Restoring Trust and Accountability in Your Organization, Third Edition

By: Sidney Dekker

Narrated by: Sidney Dekker

A just culture is a culture of trust, learning, and accountability. It is particularly important when an incident has occurred or when something has gone wrong. How do you respond to the people involved? What do you do to minimize the negative impact and maximize learning?

This third edition of Sidney Dekker's extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, retributive just culture, and the criminalization of human error.

Some suspect a just culture means letting people off the hook. Yet they believe they need to remain able to hold people accountable for undesirable performance. In this new edition, Dekker asks you to look at accountability in different ways. One is by asking which rule was broken, who did it, whether that behavior crossed some line, and what the appropriate consequences should be. In this retributive sense, an account is something you get people to pay or settle. But who will draw that line? And is the process fair? Other ways to approach accountability after an incident is to ask who was hurt; to ask what their needs are; and to explore whose obligation it is to meet those needs. People involved in causing the incident may well want to participate in meeting those needs. In this restorative sense, an account is something you get people to tell and others to listen to.

If you learn to look at accountability in different ways, your impact on restoring trust, learning, and a sense of humanity in your organization could be enormous.

©2017 Taylor & Francis Group LLC (P)2018 Sidney Dekker

case management essential

case management is a core part of safety as patients transition through the system. This is a must read!

Great book for any security professional

As security professionals we often quickly blame the end user. Oh, how come they made that mistake (i.e. clicking on a phishing link). But we just always analyze the system to understand what made them do what they did. I am grateful to Sidney Dekker and other academics researching culture’s role in understanding and preventing incidents.

culture influence on investigations

I listened to both books "Just Culture: restoring trust.." and "Field guide.." by Sidney Dekker. I recommend starting with this book because it is easier to understand and contains many good stories. Also, the writer expands on "Culture" in the filed guid book.

Very actual analysis of the psychology of safety

The book presents a very important facts based analysis of a very contemporary issue regarding justice and how much it needs to change in order to be appropriate for the current complexities and responsibilities of modern professionals and society as a whole.

What is Just?

Working in the aircraft industry can be very challenging. Lives are at stake. Being a big, public company adds financial pressures which can be fickle and immense. Having the right culture is critical. Understanding the culture is often nuanced and complex. Having the right words to express the ideas around culture can be the difference between building a healthy culture and perpetuating an unhealthy one. This book provides frameworks and language to help understand just cultures and unjust cultures. There are many helpful ideas and case studies included, but the biggest lesson I learned was about the balance each company must have between restorative justice and retributive justice. Retributive justice asks “Who messed up and how do we punish them so that justice is served?” Restorative justice asks, “What went wrong, who was hurt, how can we fix the processes, and how can we heal those who were hurt?” Retributive justice often seeks scapegoats. Restorative justice seeks learning and healing. Dekker describes three types of errors or mistakes that can be made in our high-speed work environments: 1) Human errors or honest mistakes. 2) At-risk behavior or errors made by workers dealing with great or unknown risks. 3) Negligence. Workers ignoring risks, rules, or requirements and making decisions that cause harm. The challenge is that it is often hard to draw a line between what is okay and not okay. It is hard to determine where to start consequences. Often our vocabulary and logic fail us and we do more harm than healing when sorting out what to do following an error or mistake. Justice is a matter of perspective. Dekker also spends a lot of time describing the second victims. These are the people who suffer as a result of a mistake, error, or choice they made working in these environments such as a police officer who kills someone in the line of duty, a nurse who makes a fatal medical mistake, or a pilot who causes a crash. These people are often hurt and may spend years suffering from guilt, shame, loss of credentials, jail time, or in the worst cases, they may even take their own lives after an incident. These second victims are often the scapegoats and can be forgotten or abused by retributive justice cultures. Restorative justice cultures seek these victims out too and seek to learn from them and their experiences and use those lessons to fix systems that failed. Dekker describes the following theories which are used to describe why people break the rules or make mistakes: labeling theory, control theory, learning theory, bad apple theory, stupid rules or subculture theory, and resilience theory. I’ve seen examples of all of these at work and in other areas. Understanding them helps give language to some of the interesting psychology they describe. Dekker also talks about the interesting dynamics of reporting and disclosure, and how leaders or regulators can incentivize individuals and organizations to open up about mistakes and learn from them before an accident or legal case forces the action. This isn’t a very long book, but it is packed with good lessons, examples, and language to help understand complex ideas about company cultures. I’ll reread this soon to soak up more of the lessons.

This is for anyone seeking to learn about justice.