To Punish or Not to Punish Just Culture and Accountability: Can They Co-Exist? BY PHIL LA DUKE Many in the safety community continue to stress the need to create a safety culture. I find this irritating for two reasons. First, every organization already HAS a safety culture (the codified set of behaviors that manifests the importance the organization places on safety). Second, the idea that the key to safety lies in culture isn’t new or original (the idea that a “just culture” is necessary to increase near miss or incident reporting in the aviation industry has been around since the late 1950s). In 1997, author James Reason used the term “Just Culture” to describe safety cultures that foster trust and reward people who honestly and candidly report their mistakes. But even then, the concept that people should not be punished for their mistakes wasn’t a new idea. Decades earlier, W. Edwards Deming encouraged organizations to “Drive fear from the organization.” The common thread in all these philosophies is that people make mistakes. Only when people admit their mistakes can we find the root causes of the mistakes, and people will never admit to making mistakes when doing so results in a disciplinary action. While a blame free workplace sounds nice, there is the very real threat of liability because of malpractice or negligence laws. But the problem with Just Culture often goes deeper than merely the organization’s need to manage its risk of liability. Many Just Culture efforts fail because of the dichotomy that exists between an organization’s desires to create a blame-free, problem-solving culture and its need to hold someone accountable. Who Did This? Very few societies can resist the temptation to hold someone responsible when something goes wrong. It’s in our nature to want to fix blame and punish the offender. When things go wrong someone must be made to pay for it; someone must be to blame. And the more severe the consequences— as, for example, in cases where someone dies because of a mistake—the greater the desire to punish the offender. As critics of Just Culture are sure to remind us, if an organization doesn’t hold people accountable for their negligence, carelessness, or recklessness, the organization exposes itself to an unacceptable level of liability. To Punish or Not to Punish Interestingly, advocates of Just Culture initiatives aren’t averse to punishing people— even the staunchest advocates agree that someone who engages in willful, reckless, and intentional malfeasance must be severely dealt with. But even here, things can get a bit complicated. When we take a look at errors, we’re dealing with three kinds of situations: mistakes, misjudgments, and malfeasance. Mistakes are the most forgivable of these circumstances because they are unintentional. Mistakes range from subconscious errors, to forgetfulness, or doing a job to a less than satisfactory level. Western culture darn near celebrates the fallibility of mankind. ‘To err is human; ‘That’s why they put erasers on pencils; and hundreds of other adages attest to our right as human beings to make mistakes and be forgiven for them. Our misjudgments are less forgivable because a) they are almost always intentional, and b) people often see our misjudgments as the result of either incompetence or carelessness. Where as a mistake is categorized as “honest,” misjudgments are seen as reflective of our indifference or stupidity. And certainly malfeasance—those cases where someone behaves with depraved indifference to other people’s safety or deliberately acts to harm others—is never acceptable, and those who commit such acts will certainly be disciplined maybe even prosecuted. Rules According to Dr. Patrick Hudson in “Bending the Rules,” his 1998 keynote address to the Society of Petroleum Engineers (SPE) conference of HSE in Oil and Gas Exploration and Production, the failure to follow established rules and procedures is a major contributor in many accidents in high-risk industries. People violate the rules for many reasons, sometimes for good reasons, and the Just Culture systems seek to provide procedural remedies for supervisors to decide what discipline, if any is appropriate. Unfortunately, many of these models poorly define the types of acceptable reasons for the errors people make and/or the disciplinary process relies too heavily on interpreting the individual’s intentions (did the person do it voluntarily?) Can we truly create a Just Culture if the decision about whether or not one is disciplined rests on either intention or outcome? No, and this is where many attempts at Just Culture fail. Just Culture is bigger than safety. A Just Culture is a business philosophy that permeates the entire organization’s decision making process; it’s okay to make mistakes as long as we learn from them. A true Just Culture seeks to encourage employees to live in accordance with the company’s core values, and unless honesty and integrity are core, values a Just Culture is unlikely to be sustainable. A true Just Culture organization holds people accountable first and foremost for doing what is right and for living the values of the organization over arbitrarily following the rules. Finally, an organization with a Just Culture rewards and respects those people who share the lessons they learn from their mistakes. FSM Phil La Duke, a safety consultant, can be reached at philipladuke@comcast.net.