Why you may need a committee to help interpretation of behavioural choices.

Treat the worker fairly and justly. Put him at ease.

And HOLD that judgment!

Just because the accident was very big does not mean the people involved are very bad.

Stay calm at all times. Be aware that one human error easily leads to another unintended human error.

Someting exceptional happened.

Your person was improving the system. 

People took action to help others understand and operate the system better. 

Your person was demonstrating skills working the system as it is known.

Something happened in which somebody seemed to make an error.

A rule or procedure was not followed

Although the person knew about the rule, he or she decided that for some reason this was not applicable.

Person knew there was a rule and he/she knew she broke it, but that suited him or her just fine. 

This tool proposes eight classes of human behaviour, 4 positive, 4 negative.

Your responsibility is the safety management system. And to make it work!

Making sure learning and improvement is the objective

De-identified or anonymous?

Give your general managers / directors / management team the assignment to have the just culture process designed. 

Recognizing exceptional behaviour is an important element in a just culture.

Improving the system effectively demonstrates a high level of skill. This should be recognised and rewarded.

Becoming a teacher is a major milestone in the development of a professional.

Working effectively with a system, and working it well, is no trivial achievement.

Do the routine test first

Hm! You must be puzzled and want to know WHY this happened.

O dear… Is it him again? Why can he not understand how this system works…!

Time to look for the work circumstances!

Did you see this before?

First time it happened... okay, let's dig in and go deeper.

It is him again... Yes, he does have a problem following rules. 

Either your rules are not clear or your safety culture is down.

A rule was knowingly NOT applied

Because this has not happened before, your principle assumption remains that the procedures as specified normally work and are understood by everyone. 

Yes, he does have a problem following rules.

Your safety culture is down and no-one is correcting this.

Personal gain at play!

This is one of the hardest part. Comes AFTER the internal Just Culture

The CEO is instrumental to ensure a good external Just Culture.

De-identified or anonymous? And by what means?

What to do when you observe a safety event.

What to do when you observe a safety event.

What do you do when you are part of safety event?

Some safety departments are set up as independently as possible from the operations. 

Complete information on facts, circumstances and human behaviour.

Focus on human behaviour and intent. Interview with person and other persons involved.

The interpretation of human behavioiur is best done by peers. Not by the investigator.

It is not your job to blame or punish!

Take an objective look and record for yourself WHAT happened and HOW.

Electronic, written, oral. Secure reception.

Report as quickly and timely as possible and practicable.

Secure, safe. Evidence.

Feel free and entitled to suggest improvements

The goal is to improve the workforce morale and performance.

A tool to help you in your interpretation of human behaviour.

A safety event is any event in which safety played a role, either positively or negatively.

Do: Observe, question, record, report.

Do not: blame, reject, seek guilt, hide.

Judgment by peers, not by management

A jury of peers allows professional themselves to draw the line. 

It makes a difference as to who’s behaviour you are interpreting.

Finding somebody to blame can feel very comfortable

Justice, media, police, authorities...?

Learning is safer than punishing!

Make yourself a shining example of a good safety culture!