Abstract
Building on the success of the 2007 original, Dekker revises, enhances and expands his view of just culture for this second edition, additionally tackling the key issue of how justice is created inside organizations. The goal remains the same: to create an environment where learning and accountability are fairly and constructively balanced. The First Edition of Sidney Dekker's Just Culture brought accident accountability and criminalization to a broader audience. It made people question, perhaps for the first time, the nature of personal culpability when organizational accidents occur. Having raised this awareness the author then discovered that while many organizations saw the fairness and value of creating a just culture they really struggled when it came to developing it: What should they do? How should they and their managers respond to incidents, errors, failures that happen on their watch? In this Second Edition, Dekker expands his view of just culture, additionally tackling the key issue of how justice is created inside organizations. The new book is structured quite differently. Chapter One asks, 'what is the right thing to do?' - the basic moral question underpinning the issue. Ensuing chapters demonstrate how determining the 'right thing' really depends on one's viewpoint, and that there is not one 'true stor' but several. This naturally leads into the key issue of how justice is established inside organizations and the practical efforts needed to sustain it. The following chapters place just culture and criminalization in a societal context. Finally, the author reflects upon why we tend to blame individual people for systemic failures when in fact we bear collective responsibility. The changes to the text allow the author to explain the core elements of a just culture which he delineated so successfully in the First Edition and to explain how his original ideas have evolved. Dekker also introduces new material on ethics and on caring for the' second victim' (the professional at the centre of the incident). Consequently, we have a natural evolution of the author's ideas. Those familiar with the earlier book and those for whom a just culture is still an aspiration will find much wisdom and practical advice here.
... Effective solutions for safe transportation will affect the public acceptance and the sustainability of UAM operations [9][10][11]. Given the complexity and potential risks associated with operating aerial vehicles in densely populated urban environments, cultivating a just culture is crucial for encouraging open communication and reporting safety concerns [5]. It allows stakeholders, including pilots, operators, regulators, and the public, to collaborate effectively in identifying hazards, analyzing incidents, and implementing corrective actions to enhance safety standards [12]. ...
... An effective safety management system provides the framework and tools for identifying, assessing, and mitigating risks. Its success depends on the flow of information between different levels and how the organization responds to accidents and incidents [5]. ...
... In many countries, pilots receive significantly higher wages for holding their licenses, so they are expected to shoulder the blame when necessary [22]. Such a blame culture does not consider systemic issues or latent failures, discouraging open communication and honest disclosure [5]. Recognizing this reality, numerous entities in commercial aviation, including international organizations like ICAO and regulatory bodies like the FAA, are actively working towards fostering a just culture [21,23,24]. ...
Urban Air Mobility (UAM) is an emerging industry marked by technological advancements, new operational contexts, and regulatory frameworks. This article examines how to improve safety management in UAM operations by adopting a just culture approach from a system of systems perspective. Acknowledging the critical role of front-line workers, especially in the early stage with piloted vehicles, the ecosystem-level approach comprehends multiple providers, operators, and services. Employing an enterprise architecture methodology, we address the challenge of fostering a learning-oriented environment amidst diverse organizational perspectives and stakeholders’ interests. This study identifies key capabilities, functions, and resource exchanges within and across organizations by strategically leveraging architectural views and systemic visualizations. A unified safety committee is discussed and recommended to facilitate consensus among stakeholders, including regulatory bodies, thus paving the way for industry-wide improvements. Findings contribute to evolving safety protocols in UAM operations and serve as a blueprint for integrating cutting-edge methodologies to drive systemic enhancements.
... Using this model enriches our qualitative analysis as it helps to identify the coordination and communication processes underlying system administrators' work in a structured way during complex and unusual operational situations, such as 4 59 in COVID-19 lockdown conditions. This way, we can develop a comprehensive description of sysadmins' coordination, have a starting point for formalizing this human-human coordination, provide the capability of prediction of similar coordination in the future, and finally, add to the existing body of knowledge regarding human-centered design recommendations for sysadmins' tools. ...
... Firstly, the culture of open communication and speaking up has positive effects in terms of asking for help and admitting when mistakes happen. This helps to create a culture of learning from mistakes instead of blaming for mistakes [59]. On the flip side, Participant P5 shared that coworkers might find it okay to not follow protocols in such a workplace. ...
... A restorative justice approach is one that is about reducing harm and learning from incidents, and does not focus on blame and punishment. The questions in a restorative approach therefore investigate who has been hurt, what their needs are and whose responsibility is it to meet these needs [59]. Hence, it is more about gathering peoples' honest accounts of what happened without fear of blame, and learning from these accounts [59,61]. ...
Technological systems and infrastructures form the bedrock of modern society and it is system administrators (sysadmins) who configure, maintain and operate these infrastructures. More often than not, they do so behind the scenes. The work of system administration tends to be unseen and, consequently, not well known. After all, do you think of your IT help-desk when everything is working just fine? Usually, people reach out for help when something is not working as expected or when they need something. A lot of work and effort goes into ensuring that systems are working as expected most of the time and, paradoxically, this smooth functioning results in the invisibilization of the work and effort that went into it.
This PhD research focuses on system administration work and what that entails in day-to-day tasks. Instead of proposing technical and social solutions, we try to better understand the “problem” that these proposed solutions are meant to solve. Drawing from safety science research and feminist research approaches, we perform a qualitative exploration of sysadmins’ work. We center their experiences via an in-depth interview investigation and a focus group study. We identify and describe the coordination mechanisms and gender considerations embedded in their work. We shed light on care work as part of sysadmin work and the phenomenon of double invisibility that is experienced by sysadmins who are not cis men. The thesis wraps up with a set of recommendations for moving toward safe and equitable work environments for sysadmins.
... A small amount of theory is useful in considering the challenges to exploring and changing culture. The references provide links to further reading (Waterson, 2014, Dekker, 2012, Guldenmund, 2000, but it is fair to say that most of the models in the literature reflect the concept of culture having multiple layers, often described as an 'onion'. The core of this onion is deeply hidden, and this presents challenges, both in terms of understanding and describing it but also in terms of changing it. ...
... However, there are situations where individual accountability will still be important. The concept of 'just culture' recognises this, and is built on a shared understanding of, and consensus around, where to draw the boundary between behaviours that are normal and those that are deemed negligent or reckless (Dekker, 2012). It reflects the system's thinking, recognising error is also an emergent property, but includes room for individual accountability. ...
... The reason that there is not one true story of any event is that all those involved have a different perspective and understanding of the event. Rassmussen (cited in (Dekker, 2012), p.72) formulates this problem succinctly: ...
The aim of this chapter is to help you consider aspects of organisational culture and development that are likely to impact on safety, as well as introduce tools that may be useful for you in assessing safety culture within your own organisation. Given that organisational factors strongly shape context, they are often considered ‘performance influencing factors’, and examples include staffing, workload and fatigue management.
... In response to these less effective retributive organizational responses-focusing on individual punishment or compliance-some authors have argued in favor of a restorative approach. This approach aims to achieve a culture of dialogue, fairness, forgiveness, and learning from (potential) misbehavior, also referred to as a 'just culture' (Dekker, 2012;Fehr & Gelfand, 2012;Hollnagel, 2018;Wu, 2000). In this approach, the focus shifts from individual behavior to team level interactions, and from a backward to a forward looking attitude. ...
... We reflected on emergent data, themes, concepts, and the literature on restorative organizational responses to see whether our findings had any precedent (Gioia et al., 2013). The second-order analysis work by Dekker (2012Dekker ( , 2013 turned out to be relevant. In particular, our second-order themes seemed to resemble concepts of second and third victimhood, focusing on the negative consequences for the perpetrator and other stakeholders, and how they might be countered by resilience approaches (see Wu, 2000;Dekker, 2013). ...
... Moreover, our study provides input for a further conversation on how to combine retributive and restorative responses to sexual boundary violations. Our findings acknowledge the negative impact of retributive responses (see Heraghty et al., 2020;Dekker, 2012;Leape, 1994), but for legal and moral reasons they cannot be fully prevented. There is very little empirical research on how organizations can combine retributive and restorative responses (e.g. ...
Studying and discussing boundary violations between people is important for potentially averting future harm. Organizations typically respond to boundary violations in retributive ways, by punishing the perpetrator. Interestingly, prior research has largely ignored the impact of sexual boundary violations and retributive dynamics on teams. This is problematic as teams provide an obvious setting not only to detect and discuss troubling behavior by peers, but also for learning how to prevent future harm. Therefore, in this study we explore team-level experiences regarding sexual boundary violations and organizational responses to these incidents. Drawing on an in-depth case study, our findings shed light on the profound negative consequences of a retributive organizational response to sexual boundary violations. Additionally, our findings show how a restorative approach, inviting teams to reflect on the violations and their impact, can help teams to recover. Our main contribution involves a model that demonstrates how the interplay between sexual boundary violations, retributive, and restorative organizational responses affects teams. This model shows how combining these responses can acknowledge distress within teams, heal relationships between team members through dialogue, and open up the possibility to learn from these events. This model extends prior research focusing on individual actions and outcomes regarding violations. Additionally, by combining retributive and restorative organizational responses in one model, we extend the literature on restorative organizational responses to boundary violations.
... Just Culture is a significant issue whose implementation would have an obvious advantage in promoting safety, and its implementation should be prioritized. Organizations should develop how they handle blame and punishment [1]. Just Culture can impact everyone at the unit, from Accountable Executive to operational personnel [2,3]. ...
... The guidance provided by culpability tools will interact in the decision-making process pertaining to a particular incident with the personal biases of the decision makers (such as perceptions toward authority), as well as the dynamics of their interaction with one another as a team (e.g. conformity demands), and organizational politics (as consequences of specific determinations) [1,9]. We need to really understand that the basic need for our safety is Just Culture. ...
... Referring to the same reference of determining culpability decision [1], the Indonesia Air Navigation must and will have procedure for acceptable behavior and unacceptable behavior criteria. It was intended that the Indonesia Air Navigation and its employees will know and have clear behavioral limitations, although this was not easy. ...
... Legal and safety scholars have also problematized the relationship between law and safety in aviation. For example, it has long been argued that safety reporting is negatively affected if and when human errorbased aviation incidents are dealt with through criminal justice systems (Schubert 2004, Dekker 2007, Fitzgerald 2012, Lawrenson and Braithwaite 2018, Pellegrino 2019. ...
... Given that commercial aviation is one of the most heavily regulated industries globally (Fitzgerald 2012, 2;see Huang 2009), and that scholars have long problematized negative effects of legal proceedings on safety conduct among aviation personnel (see Dekker 2007, Hodges 2015, Cromie and Bott 2016, McCall and Pruchnicki 2017 there are surprisingly few if any socio-legally framed studies that explicitly explore the legal experiences and normative complexity surrounding the working life of aviation professionals (see Woodlock 2022). As such, the research presented here is both timely and needed, where an empirical analysis of professional experiences of law and normativity in European aviation can allow bottom-up findings of legal consciousness research to contribute with better understandings of the interaction between law, legality and safety in this multi-level and market-steered regulated sector. ...
... The confidentiality and the protection of reporters and persons mentioned in reports are to be ensured in the handling of submitted reports, not least by applying "just culture" principles (see Hodges andSteinholtz 2017, Pellegrino 2019). Just culture is a concept that emerged in safety scholarship based on a long-standing argument that legal interferences generate fear before the law with safety reporting "often dealt a 'harsh blow when things go to court'" (Dekker 2007(Dekker , 21, 2011see Reason 1997, McCall andPruchnicki 2017). To alleviate fears of legal consequences, a just culture attempts to find a balance between safety and accountability by building a culture of trust and learning (Dekker 2007;see Cromie and Bott 2016, Karanikas and Chionis 2017, McMurtrie and Molesworth 2018. ...
... Accident analyses indicate the most of these instances involve several factors, most notable are component malfunction, operators' errors. In many cases the loss is attributed ad hoc to the person who happened to be on duty at the time of the event (Dekker, 2007) [4]. ...
... Accident analyses indicate the most of these instances involve several factors, most notable are component malfunction, operators' errors. In many cases the loss is attributed ad hoc to the person who happened to be on duty at the time of the event (Dekker, 2007) [4]. ...
... A just culture distinguishes between acceptable and unacceptable safety-related behaviors of employees. While willful violations are not acceptable in a just culture, honest mistakes are interested (Dekker, 2016). The reporting culture encompasses the beliefs and values that employees can report all safety risks without hesitation and voluntarily. ...
... According to the contemporary approach to the assessment of human error, human error is not viewed as the cause of an adverse event but as a symptom of a deeper problem in a defective system. This constructive view does not blame people directly or immediately when things go wrong since it adopts constructive justice practices (Dekker, 2016). ...
The aim of this research is to examine the factors affecting the concept of just culture in airline companies in the light of literature review. In the study, the phenomenological research method, one of the qualitative research designs, was preferred. The sample of the research consists of 17 experienced employees working in three big airline companies in Turkey. Interview method was used to collect data in the research. The data collected from the participants were subjected to content analysis and the themes of the research were reached. As a result of the content analysis, the factors affecting just culture in airline companies were gathered under five themes. These themes are; factors related to organizational structure and processes, factors related to managers, factors related to employees, factors related to error and violation distinction, and factors preventing just culture. These factors were classified as major, enhancer, and prospective factors by the researchers in terms of their effects on just culture. It is thought that the research will make an original contribution to just culture literature.
... 28 Eliminating the fear of consequence is crucial to building trust and establishing that reporting will not negatively affect the staff member voicing their concerns or the member of staff involved in a report. 29 Elimination of fear of consequence builds on staff trust, ensures positive feedback, and provides learning opportunities from the reported event. 29,30 Our research recognized the importance of acknowledging positives during debriefs. ...
... 29 Elimination of fear of consequence builds on staff trust, ensures positive feedback, and provides learning opportunities from the reported event. 29,30 Our research recognized the importance of acknowledging positives during debriefs. Positive feedback was seen as an effective way to encourage individuals to speak up and develop a structure that makes space for positives. ...
... The second revolutionary field, high transparency and more efficient inspection, has already inspired the aviation sector. In this sector, a mature system of procedures and agreements is worked out to deal with the reporting of all incidents and near-misses in order to learn as much as possible in a 'just culture' setting (Dekker, 2012). Accordingly, the following innovative approaches can be introduced and elaborated in the chemical industry worldwide: ...
... Meel et al., 2007) • Establish a 'just culture' in chemical plants/clusters (see e.g. Dekker, 2012) • Establish a dissemination system where companies and authorities/inspection teams can learn from all incidents happening within the industry • Establish an understanding between cluster safety council members and inspection services to make inspections more efficient • Use drones to continuously gather data from around the cluster Besides efficiency improvements, inspections should evidently also be more effective. Often, the quality of inspections is below a level that might be expected in case of chemical industrial activities. ...
This paper argues that a new concept, summarized as ‘CHESS’, should be used in the chemical industry to further substantially advance safety (where we use the term in a broad sense, that is, safety and physical security, amongst others). The different domains that need to be focused upon, and where innovative initiatives should be taken are Cluster-thinking and cooperation, High transparency and efficient inspections, Education and training, Security integration, and Safety innovation. Since society has fundamentally changed over the last two decades, and ever more hazardous materials are used in chemical sites which are ever more closely situated next to highly-populated areas, revolutionizing safety via the CHESS concept is truly needed in the very near future, both from a safety and a security point of view.
... Healthcare organizations should develop just culture in all levels from leaders and managers to front-line workers [9,14]. In just culture, front-line workers are not blamed or punished, but ensured fair investigations are in place [12], and after an incident, the question asked is, "What went wrong?" rather than "Who caused the problem?" [15]. ...
... A no blame culture gives people a false sense of their actions and mistakes have no impact on the patient and organization [12]. Just culture, on the other hand [9], assigns responsibility and accountability for the consequences of their actions [14]. Healthcare organizations cannot afford a blame-free culture and that some errors do warrant disciplinary action [12]. ...
Background The non-punitive approach to error investigation in most safety culture surveys have been relatively
low. Most of the current patient safety culture measurement tools also lack the ability to directly gauge concepts
important to a just culture (i.e. perceptions of fairness and trust). The purpose of this study is to assess nurses’ percep‑
tions of the six just culture dimensions using the validated Just Culture Assessment Tool (JCAT).
Methods This descriptive, cross-sectional study was conducted between November and December 2020. Data
from 212 staf nurses in a large referral hospital in Qatar were collected. A validated, self-reported survey called
the JCAT was used to assess the perception of the just culture dimensions including feedback and communication,
openness of communication, balance, quality of event reporting process, continuous improvement, and trust.
Results The study revealed that the overall positive perception score of just culture was (75.44%). The strength areas
of the just culture were “continuous improvement” dimension (88.44%), “quality of events reporting process” (86.04%),
followed by “feedback and communication” (80.19%), and“openness of communication” (77.55%) The dimensions
such as“trust” (68.30%) and“balance” (52.55%) had a lower positive perception rates.
Conclusion A strong and efective just culture is a cornerstone of any organization, particularly when it comes
to ensuring safety. It places paramount importance on encouraging voluntary error reporting and establishing
a robust feedback system to address safety-related events promptly. It also recognizes that errors present valuable
opportunities for continuous improvement. Just culture is more than just a no-blame practice. By prioritizing account‑
ability and responsibility among front-line workers, a just culture fosters a sense of ownership and a commitment
to improve safety, rather than assigning blame.
... However, after checking, it becomes clear that in the world of science, SS is a different scientific stream than SSC and that it is much broader than international studies (IS), a sub-discipline of political science, which, incidentally, also belongs to the sphere of social sciences -which is a contribution to justifying the affinity of these trends. The subject of research in the sub-discipline of international relations is, for example, "social relations that take shape across national borders (…)" 41 and is undeniably interesting to security studies. When elaborating on particular threats and challenges to the security of the state, it is important to understand international relations from which threats can arise precisely from that geopolitical zone. ...
... It is clear, without the need to verify it by means of an additional experiment that these two scientific currents do not exist in two different social realities, but in exactly the same social space. 41 42 The combined technological and IT revolutions generate an egoistic-consumptive lifestyle, social atomism and aggressive attitudes, the good of others becomes of little importance and the mass media promote any kind of violence as originality. Daniel Goleman, for example, notes in the context of a certain "fashion" for violence that "despite their [children's with above average IQ scores] intellectual potential, these are the children at highest risk for problems like academic failure, alcoholism, and criminality -not because their intellect is deficient, but because their control over their emotional life is impaired" -D. ...
In From Security Science to Security Culture, authors Juliusz Piwowarski and Darko Trifunović add to the growing body of literature about security science, in particular, how security science can contribute to the development of a security culture. One of the challenges facing the development of security science as an academic discipline is that, in the view of some, security science as compared to the traditional disciplines, lacks validity. Nonetheless, the topic has generated a cornucopia of books and articles discussing the nature and methodology of this emerging discipline. Smith and Brooks, for example, argue that Security Science allows the scientific method to be applied to security issues, indicating that logical thought can be applied to further the development of security science and enable security science to become an effective tool that can be applied to the protection of people, assets, and information. Piwowarski and Trifunović add to this viewpoint and take it a step further by explaining the methods and steps by which security science can lead the way to the development of a security culture.
Emphasizing the growth of security science as an academic discipline in Poland and Serbia, the authors outline the process by which this evolution can take place. Noting the ongoing proliferation of security risks, they argue that security science provides the best method for amalgamating a variety of academic disciplines and social practices that can bring about the emergence of a security culture which can produce a unique discipline which may enable the creation of improved security risk assessments that can come from within a state or from sources beyond a state’s borders. Interestingly, the authors argue that Security Science “… cannot be a sub-discipline, instead, all other social sciences can become a sub-discipline of Security Science.”
Drawing on a variety of sources ranging from the humanities to various social science disciplines, the authors emphasize the work of Professor Barry Buzan and the Copenhagen School. They especially note the Copenhagen School’s emphasis on the non-military elements of security assessment, which was a step away from the more traditional focus of security experts. This has allowed the emergence of this newly emerging academic discipline now known as Security Science.
Through what they call the Security Rhombus, the authors detail the process by which security science can drive a process that will produce, first, a security environment, defining and explaining in detail what brings about a security environment and its creation. Out of this will emerge a culture of security. The authors credit the Copenhagen School for expanding research to include a focus that goes beyond nation-states. This, they assert, has created a more interdisciplinary approach to the study (or science) of security, so that research can range from human interactions, to national and then to international security. Ultimately, the authors demonstrate the essential importance of a national security culture as the foundation of an overall security culture. They conclude by warning, that, even with globalization, nation states would do well to focus on their own security resilience as a safeguard in the event of global catastrophe.
The authors have produced a thoughtful argument about the purpose and goals of the newly emerging academic discipline of security science. Piwowarski and Trifunović’s support for and belief in the importance of security science is evident throughout the manuscript and emphasizes the importance, in their view, of the discipline and how it may transform and improve research into the varied aspects that challenge security professionals and those who study security issues. The emphasis on an interdisciplinary approach to studying security concerns, whether from an academic or professional level, is especially welcome as this approach may well be the best method of dealing with the proliferation of challenges to human security, whether from an individual, social, community/national or international perspective.
Gregory Moore, Ph.D.
Professor of History & Security Studies
Director, Center for Intelligence Studies
Department of Public Service & Security Studies
Notre Dame College
South Euclid, Ohio USA 44121
... Weighing up such risks can serve to highlight or generate uncertainty, especially in multi-disciplinary settings. Yet, working with that uncertainty is less than straightforward where social workers are expected to minimise it when determining what constitutes risk and who is at risk, whilst having to avoid the dangers of making the 'wrong' decision within organisations that have increasingly adopted a blame culture (Dekker, 2007;Armstrong et al., 2018). Thirdly, intervention strategies often involve sanctions and controls to manage the risk (Barter, 2013), and this can lead to increased tensions and uncertainty where a strengths-based approach is selected to promote the child's protective factors and resilience (Daniel et al., 2010). ...
... This can lead to deleterious if not dangerous outcomes for a child and the public. Dekker's (2007) view of a 'just culture' seems relevant to addressing some of these organisational and cultural practices along with the low frequency of uncertainty found in this study. For Dekker, it is the opportunity to reflect on a just culture rather than a blame culture that will help create a practice environment where staff feel supported to explore uncertainty. ...
Uncertainty in thinking and reasoning is crucial in allowing professionals to engage with the complexities of practice, yet the way it is expressed in childcare social work remains under-researched. This study examines the uncertainty expressed by professionals when discussing children who present a serious threat of harm to others. Discourse analysis is used to examine data from twenty meetings involving seventy-five professionals. The findings suggest that there is considerable variance in the way professionals express uncertainty and in many of the meetings it appears to be relatively infrequent. The low levels of expression of uncertainty in such complex cases are problematic because it reflects limitations in professionals’ thinking and actions. The majority of instances of uncertainty occur in response to a question from another professional. This is a positive aspect of professional interaction and suggests that robust questioning from peers that encourage analysis of our practice might be particularly useful in prompting uncertainty. Rather than ignore or supress uncertainty by viewing it in negative terms, it should be valued and embraced by professionals who want to reduce unnecessary errors and enhance children’s safety.
... In a just culture, workers are assured that they will be treated fairly in the event they engaged in an unsafe act and are willing to self-report because a culture of trust has been established between themselves and management. Workers are also able to express their views in investigations because they are confident that the system will protect them ( Dekker, 2007 ). Safety justice in a risk-prone workplace is important because it makes it easy for the management to collect data from workers for the purpose of improved safety performance through incident reporting. ...
... Accountability in a just culture, according to Dekker (2007 ), may be forwardlooking or backward-looking. In forward-looking accountability, the goal is to find opportunities for organisational learning and using the supposedly sad events to set up policies which ensure that the likelihood of reoccurrence of a similar or the same event is either eliminated or reduced to the barest minimum. ...
... As described by Syed [41] and Dekker [42], such a situation is caused by the absence of an open safety culture that promotes sufficient communication among staff without a fear of blame for operational failure. Dekker [42] has suggested that placing blame undermines workers' ability to learn from failures and instead decreases the openness of failures. ...
... As described by Syed [41] and Dekker [42], such a situation is caused by the absence of an open safety culture that promotes sufficient communication among staff without a fear of blame for operational failure. Dekker [42] has suggested that placing blame undermines workers' ability to learn from failures and instead decreases the openness of failures. Syed [41] has also described that fully disclosing incidents is necessary to learn from failures and foster an open safety culture. ...
Similar crashes or incidents may recur as a result of insufficient communication in uncertain and risky situations that potentially threaten safety. The common root causes of insufficient communication across a series of incidents and crashes must be explored in detail to prevent a vicious circle of similar incidents or crashes from occurring. This study summarizes a series of incidents and crashes (derailment due to excessive train speed) at JR West at the West Japan Railway Company (JR West) that are considered to have arisen from insufficient communication. The incidents included (i) resuming train service without confirming the number of passengers on board and leaving passengers behind the station at Higashi-Hiroshima station, (ii) continuing train service in spite of an apparent risk of a crash detected at Okayama station, and (iii) leaving the crack of the train hood as it was at Kokura station. We discuss the causes of insufficient communication (particularly in relation to the sharing of information) among the three branches of staff—the station staff, the conductor and train driver, and the train operation management center—that led to the incidents or crashes. Two factors contributed to the insufficient communication in the series of incidents and crashes: (a) Asymmetry of authority, which hinders the discussion of issues openly and equally among the branches concerned. (b) An unacceptable level of knowledge or information for all branches concerned.
... This means that according to this new view of human error, to do something about the incident, instead of doing something about the particular individual, one must analyse the system in which people work. Hence, one should for instance evaluate the production pressure, the existence of goal conflicts and the design of equipment and procedures (Dekker, 2007). There are a variety of definitions of what a safety culture is. ...
... The main point of reporting is to contribute to organisational learning and help preventing recurrence of undesired events. This means that any event that may help increase safety is worth reporting (Dekker, 2007). According to The Heinrich Pyramid, also known as the iceberg theory, safety triangle or accident pyramid (Figure 16), the analysis of events that had the potential to cause harm, but never did, provides an opportunity to prevent future errors before they occur. ...
This report analyzed the impact of various organizations and stakeholders in the marine industry on the safety of shipping. Different research methods, including literature studies, data analysis, and interviews with ship management companies, were used to study the organizational impact on the human factor in shipping. The results of the study showed a strong correlation between various organizational influences and the chance of having or not having incidents with a vessel. The study found that ship owners, ship managers, ship operators, insurance companies, ship yards, classification societies, flag states, and vetting inspections and port state control all had a statistically significant impact on safety. The study also found that various organizations had an impact on the ship's safety during the design phase, and that ships between a certain age range were more likely to be involved in accidents. The report concludes that different quantitative and qualitative methods can be used to study the safety culture and organizational impact on safety, and that management participation and involvement in work and safety activities, as well as frequent, informal communications between workers and management, are critical behaviors. The report suggests improvements based on sharing of knowledge across the industries, management commitment and style, the implementation of safety systems, communication issues, the supportive environment and employee involvement.
This report aims to analyse the impact of the various organisations and stakeholders in the marine industry on the safety of shipping. The research problem addressed is the organisational impact on the human factor in shipping.
Different research methods have been used. The study compromises a literature study on what has been done in this regards in other industries, a data analysis coupling different databases in a unique way together to derive the impact of the different stakeholders on accident frequencies and finally an interview/ data collection part from ship management companies.
The results of the study can be summarised as that there is a strong impact of various
Organisational influences on safety can be shown via this analysis are ship owners, ship managers, ship operators (including their office location), insurance companies, ship yards, classification societies, flag states, and even vetting inspections and port state control. All of these show a statistical significant correlation to the chance of having or not having incidents with a certain vessel.
Speaking in terms of latent factors it becomes obvious that various organisations have an impact on the ship’s safety, whose decision, for instance in the design phase of the vessel have an impact on safety.
Some results might be obvious intuitively like that ships between a certain age range are more likely to be involved in accidents (10-15 years of age). Others are less obvious such as that ship owners or ship managers in many western countries are more likely running ships involved in accidents. All of the results presented here are statistically significant, but the causal influence or direction cannot be scientifically proofed.
Conclusions based on this study can be summarized as:
Different quantitative and qualitative methods have been suggested based on the literature study and used in order to study the safety culture and organizational impact on safety. Specifically, management participation and involvement in work and safety activities, as well as frequent, informal communications between workers and management, are recognized as critical behaviours.
The category “human factor accidents” is the predominant category when it comes to “causes” in the databases used. Looking into details of causes in the database, quite a share of the incidents can be directly connected to latent or organisational deficiencies such as heavy workload, inadequate training, improper ergonomics, the use of violence, assault, etc. and inadequate staffing. Even in other categories the latent factors are underlying and could be identified as contributing factors as well as those connected to the management onboard. There are uncertainties connected with the use of such databases for identifying latent errors, but the analysis intended only to give a first indication. So it is rather a question on where the human factor has its most significant influence on the ship, on the bridge or onshore?
Studying the Port State Controls some general conclusions can be drawn. The PSC have a positive effect on detecting sub-standard vessels and detain or ban them. The detention rates are decreasing in the latest years giving hope to believe that the standards worldwide improve. There is a huge difference of outcome based on e.g. the flag state, ship type, classification society, a fact that seems to be accepted within the industry, but does not directly follow a law of nature.
Additionally it can be concluded that some vessel types are more likely to be involved in accidents, indicating that there is a difference on how shipping companies handle vessels and that there is a close link to the handling and general acceptance of different ship standards, crew standards, safety management, equipment and standards, and maintenance levels of ships.
Improvements are often suggested based on sharing of knowledge across the industries, Management Commitment and Style, the implementation of Safety Systems, Communication issues, the Supportive Environment and Employee Involvement. Leading objective indicators of safety could not be identified across organisations in the shipping industry. The indicators that were found cannot be said to be valid since they are largely based on data of poor comparability and far from objective.
Most of the problems that the authors encountered can be traced to the aim to find common indicators by involving several different sectors of shipping companies, as the definitions of concepts used in their safety work vary considerably. Hence the authors draw the conclusion that in order to enable safety research, collaboration and comparison between different shipping companies in the future there is a need to reduce the diversity of definitions that are used within the shipping industry. Even though the method used in this part of the project proved to have a lot of weaknesses, the author’s opinion is that there is a need for a future development towards a more proactive way to manage safety in shipping. As opposed to how safety is measured today, with lagging key performance indicators, the authors believe that there needs to be a development towards a measurement of safety as the presence of something positive. The author’s opinion is that the research community should continue to develop the usefulness of leading objective indicators and that organisations can contribute to this development by implementing them as a complementary tool in their safety management systems.
... Finally, further research opportunities are suggested, and the research limitations are discussed. Dekker (2007) has noted the need of the organisation to develop a working environment and establish a just culture resulting in that employees experience safe environment, and their management is committed to safety, is aware of employees' risk behaviour, and encourages employees to identify and inform about near-misses and errors (Dekker, 2007). Just culture is specified as a culture of trust, in which there is a clear distinction of what is allowed and not allowed. ...
... Finally, further research opportunities are suggested, and the research limitations are discussed. Dekker (2007) has noted the need of the organisation to develop a working environment and establish a just culture resulting in that employees experience safe environment, and their management is committed to safety, is aware of employees' risk behaviour, and encourages employees to identify and inform about near-misses and errors (Dekker, 2007). Just culture is specified as a culture of trust, in which there is a clear distinction of what is allowed and not allowed. ...
There are a few ways how to increase the rate of employees’ safety culture at an institution, one of these is a positive safety culture, which includes their proper attitudes, safety-related values, staff members’ professional competences, and their willingness to work. The key element in the offering of quality and safe services in healthcare is a positive safety quality according to definitions. The aim of the current paper is to identify potential predictors of employees’ safety behaviour and determine safety culture subcultures that support operational manager to develop proactive safety management systems (SMSs) and offer safety of patients and employees. Two independent surveys were the basis of the new proposed approach. Quantitative method approach was selected to investigate safety culture subcultures in Estonian healthcare and nursing institutions. According to the proposed approach, there are crucial subcultures (e.g., just, reporting, learning, professional competences, and psychosocial well-being), which should be developed and periodically evaluated within an organisation. This measurement should have a clear and shared understanding of patient safety goals and occupational health and safety (OHS). The general management of organisations should consider implementation of assessment as a proactive approach to use the SMSs. The sustainability and proactivity of the proposed approach lies in defining action plans for continuous improvement and employees’ involvement in patient safety and OHS management.
... Wie is verantwoordelijk om daaraan tegemoet te komen? En welke rol spelen de organisatie en de omgeving bij het herstel en bij het leren van deze situatie?' (Dekker, 2012). ...
Veel organisaties willen de sociale veiligheid op de werkvloer vergroten. Zij doen dit veelal met top-down maatregelen zoals het opstellen van gedragscodes, het oprichten van meldpunten en aanscherpen van regelgeving. Deze maatregelen lijken echter maar beperkt effectief. Voor duurzame gedragsverandering is het van belang aan te sluiten bij de ervaringen, problemen en visie van de werknemers op de werkvloer. In dit artikel presenteren de auteurs een actieonderzoekmethodiek voor het versterken van sociale veiligheid zoals ontwikkeld bij Defensie. Deze methodiek kent vier pijlers: a) praktijkverbetering in lokale proeftuinen, waarbij geëxperimenteerd wordt met nieuwe initiatieven, b) ontwikkelen en verspreiden van kennis, c) versterken en ontwikkelen van netwerken van enthousiaste medewerkers om draagvlak te creëren, lokale initiatieven op te schalen en kennis te verspreiden en d) verankering van interventies en kennis in netwerken, beleid, opleidingsmateriaal en mensen. Besproken worden de (morele) dilemma's die inherent zijn aan deze methodiek, bijvoorbeeld risico's rondom kwetsbaarheid, diepgang versus omvang en 'wat hoort werkt niet, en wat werkt hoort niet'. De auteurs concluderen dat actieonderzoek een kansrijke methodiek biedt om te werken aan het versterken van sociale veiligheid. De methodiek levert inzichten op over wat sociale veiligheid in de specifieke defensiecontext betekent, en vergroot de handelingsbekwaamheid van de deelnemers.
... The civil defense authorities might divert the focus of accident investigation to operators or users of the alarm system. The authorities might be in a defensive position about the accident, and consequently they might blame the victims, instead of looking for ways to prevent repeating the accident (Dekker, 2007). This issue may be resolved by adopting the recently developed approach of safety culture. ...
Throughout the short history of Israel, the local population is occasionally exposed to attacks by its neighboring armies and terror groups. The Israeli intelligence provides warnings about possible gun, mortar, rocket or missile attacks, and these warnings are typically communicated to the population via traditional oscillating sirens. The Israeli civilians are instructed to run to a nearby shelter and hide there, or to take an immediate refuge.
The article proposes a methodology for evaluating alarm systems, and presents a study evaluating war alarms employing this methodology.
The design of war alarms should comply with resilience engineering holistic approach, based on analysis of all possible failures.
... A use error is a mishap in which a human operator is involved. Typically, such mishaps are attributed to the failure of the human operator (Dekker, 2007) A force majeure is a mishap that does not involve a human being in the chain of events preceding the event. ...
Intelligent Transportation Systems (ITS) provide means to reduce the rate of accidents proactively. Such systems provide car drivers with warnings about multiple potential crash hazards (i.e., forward and side collisions, running off the road, or too aggressive driving). It is hoped that such warning systems may decrease the number and severity of motorist injuries and fatalities.
Use errors hamper the effectiveness of other industries, resulting in productivity loss, damage to property, high costs of customer support and customer dissatisfaction. The other industries may benefit from applying the methodology introduced in the URM document, which is demonstrated in this research.
Extensive and expensive validation testing should be conducted to approve each particular IVCAW. It is not clear yet what sensors should be required to include in vehicles participating in field testing.
... A barrier to learning from operational failure is the accountability bias, namely, attributing failure to an operator, instead to the design (Dekker, 2007). The problem with the accountability bias is in diverting the investigation focus from the design problem to blaming. ...
The MX981 incidence demonstrates a need for early detection of assembly errors, and a method based on capturing exceptional values of the sensor measurements. This simple method may be applied to many sensors of continuous variables and contribute to the productivity and safety of many systems, in many industries.
Moreover, this method may be applied to any system variable, such as component performance, process time, and inter-state and process transition time.
It is proposed here that system engineering standards may include a chapter on when and how to apply this method.
... The second component that this study included is residents' perceptions of PS, which refers to how safe individuals feel about speaking up without fear of negative repercussions (Edmondson 1999). This key component of the CLE (Appelbaum et al. 2021) is tied to learning and performance (Hirak et al. 2012) and is a factor in the 'just culture' concept (Dekker 2012). As a more positive CLE would include higher POS and PS, it is anticipated that the residents in better CLEs will experience lower levels of stress. ...
Purpose:
The clinical learning environment (CLE) affects resident physician well-being. This study assessed how aspects of the learning environment affected the level of resident job stress and burnout.
Materials and methods:
Three institutions surveyed residents assessing aspects of the CLE and well-being via anonymous survey in fall of 2020 during COVID. Psychological safety (PS) and perceived organizational support (POS) were used to capture the CLE, and the Mini-Z Scale was used to assess resident job stress and burnout. A total of 2,196 residents received a survey link; 889 responded (40% response rate). Path analysis explored both direct and indirect relationships between PS, POS, resident stress, and resident burnout.
Results:
Both POS and PS had significant negative relationships with experiencing a great deal of job stress; the relationship between PS and stress was noticeably stronger than POS and stress (POS: B= -0.12, p=.025; PS: B= -0.37, p<.001). The relationship between stress and residents' level of burnout was also significant (B = 0.38, p<.001). The overall model explained 25% of the variance in resident burnout.
Conclusions:
Organizational support and psychological safety of the learning environment is associated with resident burnout. It is important for educational leaders to recognize and mitigate these factors.
... Preskill and Torres (1999) suggested evaluative inquiry process for enabling organizational learning within a climate of trust and honest communication. Dekker (2016), Lucier (2003), and Reason (1997) argue that by creating an environment where team members feel safe to document their mistakes without fear of repercussions, organizations can establish a valuable knowledge system. ...
Despite various government initiatives and substantial unutilized funds in the Indian Universal Service Obligation Fund (USF), a significant population in rural and remote areas still lack broadband services due to inadequate consideration for demographic and geographical challenges in planning and implementation strategies, mainly stemming from focus on quick electoral benefits, favoritism, organizational politics and a sense of indifference. This study employs a multiple‐case approach to analyze the USF institution using the proposed integrated organizational learning framework, offering a novel perspective. The proposed framework identifies factors influencing effective outcomes and provides a comprehensive assessment of cross‐project learning culture within the organization. Additionally, by unveiling systemic deception and hidden intentions, the application of this framework may act as a deterrent to improper practices, contributing to an improved outlook for future projects. Our analysis reveals that despite encountering distinct experiences and outcomes in different initiatives, the USF has missed opportunities to fully leverage lessons learned and avoid repeating past mistakes. To bolster the efficacy of future projects, we propose that the USF adopt a proactive organizational learning strategy involving thorough evaluations and analyses of past projects by experts. This process should aim to extract key lessons, challenges, and best practices, culminating in establishing a repository of learnings. Regularly updating and utilizing this repository can foster a culture of continuous improvement and informed decision‐making. Such an approach can improve project delivery across traditional metrics of time, cost, and quality and maximize benefits delivered to beneficiaries.
... culture principles within organizations, advocating open communication, and utilizing incident reporting and investigation processes as opportunities for learning and improvement (Dekker, 2016;Edwards, 2018). Implementing effective knowledge management systems can facilitate organizational learning and the sharing of safety-related information and best practices (Hallowell, 2012;Aziz et al., 2014). ...
This review explores the evolving landscape of process safety, emphasizing the integration of digitalization and advanced technologies. It assesses the role of the industrial Internet of Things, artificial intelligence, and machine learning (ML) in enhancing safety protocols. The paper examines predictive analytics, sensor technology advancements, and digital twins' contributions to safety optimization. It also discusses the future perspectives of risk management approaches, including proactive safety management systems, quantitative risk assessment techniques, and human reliability analysis. This comprehensive analysis provides insights into future developments and challenges in process safety.
... In an organizational environment where this sub-dimension has developed, employees are expected to report their errors without fear in a culture dominated by trust and free from a punitive approach. In a learning culture, attitudes, behaviours, and actions that promote organizational learning against safety hazards are valued (Bükeç & Gerede, 2017;Dekker, 2007). Flexible culture, on the other hand, denotes an organization's effective adaptation to changing circumstances. ...
Just Culture, a sub-dimension of safety culture, has been a prominent and debated topic in aviation safety in recent years. Just culture signifies a work environment where employees are motivated to provide essential safety-related information, but a clear distinction must be made between acceptable and unacceptable behaviours. The aim of this study is to examine the fundamental characteristics of just culture in the aviation sector. The phenomenology method, one of the qualitative research designs, has been adopted in the study. Purposeful sampling was used in the selection of participants, with the sample consisting of 78 students studying in the aircraft maintenance department of a public university in Turkey. The metaphor method was used to collect data in the research. The data collected from participants were subjected to content analysis, leading to the identification of the themes of the study. Content analysis revealed five fundamental themes that highlight the characteristics of just culture in the aviation sector. In this context, “providing balance and trust, being based on mutual relations, having systematic functioning, being contradictory, and being unique” were perceived as the core features of just culture. In the research, the metaphor most frequently associated with just culture was primarily the scale, followed by the utopia metaphor. Despite being an important managerial approach for aviation safety, the observation of some negatives in practice is a significant finding of the study. It is anticipated that the research will contribute uniquely to the literature on aviation safety and just culture
... Grounded in principles of equity and accountability, just culture seeks a balanced approach, reconciling individual responsibility with systemic enhancement. This approach advocates for a learning culture that encourages open discourse surrounding errors, thereby contributing to overall patient safety (Dekker, 2007;Marx, 2001). Ethical decision-making models, exemplified by principles articulated in biomedical ethics, provide a conceptual lens through which the ethical dimensions of medical errors can be scrutinized. ...
... To encourage near-miss reporting, it is advised that organizations have a "just" culture as opposed to a "blame" culture (Dekker, 2009(Dekker, , 2012Dekker & Breaky, 2016). In the latter, errors and violations are punished. ...
As today's engineering systems have become increasingly sophisticated, assessing the efficacy of their safety‐critical systems has become much more challenging. The more classical methods of “failure” analysis by decomposition into components related by logic trees, such as fault and event trees, root cause analysis, and failure mode and effects analysis lead to models that do not necessarily behave like the real systems they are meant to represent. These models need to display similar emergent and unpredictable behaviors to sociotechnical systems in the real world. The question then arises as to whether a return to a simpler whole system model is necessary to understand better the behavior of real systems and to build confidence in the results. This question is more prescient when one considers that the causal chain in many serious accidents is not as deep‐rooted as is sometimes claimed. If these more obvious causes are not taken away, why would the more intricate scenarios that emanate from more sophisticated models be acted upon. The paper highlights the advantages of modeling and analyzing these “normal” deviations from ideality, so called weak signals, versus just system failures and near misses as well as catastrophes. In this paper we explore this question.
... One study examined a company whose management implemented Just Culture approaches, saw positive results, but prematurely interrupted progress when the values of transparency and vulnerability were required and perceived of as too high a risk, since they threatened traditional practices of being able to make decisions behind closed doors without requiring explanation. 77 Although more outcome data are needed, evidence suggests that RJ can save health care organizations money by improving internal processes, 33 better addressing malpractice concerns, 50,51,57 applying effective public health interventions, 78 improving accident processes and employee accountability, 79,80 supporting health care workers, 34,63 and bolstering the culture of health care. 58 Perhaps the biggest barrier to overcome is hubris. ...
Purpose: Restorative Justice (RJ) as a practice and mindset is growing within academic medicine and health care. The authors aim to categorize the extent to which RJ training and practices have been researched, explored, and applied within health care, medicine, and academic contexts.
Methods: In July 2021, the authors conducted a scoping literature review, searching four databases for peer-reviewed articles and book chapters discussing RJ. Authors also used bibliography searches and personal knowledge to add relevant work. Reviewers independently screened article titles and abstracts, assessing the full texts of potentially eligible articles with inclusion and exclusion criteria. From each included article, authors extracted the publication year, first author's country of origin, specific screening criteria met, and the depth with which it discussed RJ.
Results: From 599 articles screened, 39 articles, and books were included (published 2001–2021). Twenty-five (64%) articles discussed RJ theory with few describing application practices with substantial depth. Ten (26%) articles only referenced the term “restorative justice” and seven (18%) discussed legal applications in health care. Fifty-four percent were from outside the United States. Articles tended to describe RJ uses to address harm and often missed the opportunity to explore RJ's capacity to proactively build community and culture that helps prevent harm.
Conclusions: RJ in health care is a rapidly expanding field that offers a framework capable of building stronger communities, authentically preventing and responding to harm, inviting radical inclusion of diverse participants to build shared understanding and culture, and ameliorate some of the most toxic and unproductive hierarchical practices in academics and medicine. Most literature calls to RJ for help to respond to harm, although there are very few well-designed and evaluated implementations. Investment in RJ practices holds significant promise to steer our historically hierarchical, “othering” and imperfect systems to align with values of justice (vs. punishment), equity, diversity, and inclusion.
... Despite years of calls for the adoption of a Just Culture, it has been observed that healthcare organizations still apportion blame to individuals all too easily and too frequently. 1,2 Wu and Kachalia suggest that our insights from frontline staff involved in incidents regarding the "justness" of the Just Culture framework are incomplete and highlight the need to examine the relationship between Just Culture, the appropriateness of the remedy, and workers' willingness to uphold key characteristics of safety culture thereafter. 2 The Just Culture approach aims to strike a balance between not blaming individuals for "honest" mistakes and holding them to account for reckless behavior. 3 Kirkup outlines succinctly that while this approach might be well intentioned, its practical application via so-called Just Culture algorithms falls short of expectations and might even be counterproductive. ...
Despite years of calls for adoption of a Just Culture, it is evident that taking this concept from paper to practice has been slower than expected. Many have cited the subpar application of the Just Culture framework and, recently, questions have been raised regarding how the Just Culture framework is perceived by those impacted by harm, including patients, family members, and staff. Though this framework is one tool that can be used to guide inquiry after harm events, its use, independent of active efforts toward restoration of relationships with patients, families, and staff, could compromise engagement and therefore learning. A lack of focus on restoring the trust of those affected by harm in parallel with the event investigation introduces a risk of further compounding the harm for all involved. Those involved in safety work at NHS England have recognized the need to apply a systems mindset within a concerted effort toward more compassionate engagement for optimal learning and improvement. In response, they have included compassionate engagement and involvement of those affected by patient safety incidents as a foundational pillar in the NHS England Patient Safety Incident Response Framework.
... Dans ces unités, parmi d'autres résultats, les auteurs montrent que les pratiques communicationnelles ou « dialogiques » (Faraj et Xiao, 2006) (Brustlein, 2001) constituent des pratiques centrales dans ce type d'équipes : pour apprendre individuellement et collectivement, il faut se nourrir des erreurs et de démarches réflexives qui ne blâment pas les premières (Catino et Patriotta, 2013 ;Gautier, 2015 ;Godé, 2016 ;Madsen et al., 2006 ;Melkonian et Picq, 2010 ;Zhao et Oliveira, 2006). Ces pratiques sont plus ou moins formalisées selon la nature des missions, leur ampleur mais aussi la culture interne des professions (Dekker, 2012 ;Sagan, 1993). ...
... Hij hangt een gedachtengoed aan dat hij Safety Differently noemt en heeft ook veel geschreven over Just Culture. Safety Differently stelt, net als Safety-II, traditionele opvattingen over veiligheid en ongevallenpreventie ter discussie(Dekker, 2012;Dekker & Conklin, 2022). Dit gedachtengoed beweegt weg van de traditionele veiligheidsbenadering van regels, procedures en naleving, maar benadrukt meer het belang van menselijke prestaties, complexiteit en systeem interacties; mensen maken fouten, en deze fouten zijn niet noodzakelijkerwijs de oorzaak van ongevallen. ...
... Firstly, the culture of open communication and speaking up has positive effects in terms of asking for help and admitting when mistakes happen. This helps to create a culture of learning from mistakes instead of blaming for mistakes [19]. On the flip side, Participant P5 shared that coworkers might find it okay to not follow protocols in such a workplace. ...
In the system and network administration domain, gender diversity remains a distant target. The experiences and perspectives of sysadmins who belong to marginalized genders (non cis-men) are not well understood beyond the fact that sysadmin work environments are generally not equitable. We address this knowledge gap in our study by focusing on the ways in which sysadmins from marginalized genders manage their work in men-dominated sysadmin work spaces and by understanding what an inclusive workplace would look like. Using a feminist research approach, we engaged with a group of 16 sysadmins who are not cis-men via six online focus groups. We found that managing the impact of gender identity in the sysadmin workplace means demonstrating excellence and going above and beyond in system administration tasks, and also requires performing additional care work not expected from cis men. Furthermore, our participants handle additional layers of work due to gender considerations and to actively find community in the workplace. We found that sysadmins manage by going above and beyond in their tasks, performing care work and doing extra layers of work because of gender considerations, and finding community in the workplace. To mitigate this additional workload, we recommend more care for care work. For future research, we recommend the use of feminist lenses when studying sysadmin work in order to provide more equitable solutions that ultimately contribute to improving system security by fostering a just workplace.
... Incident reporting systems are a fundamental and mandated component of safety management across safety critical domains ( Jacobsson, Ek, & Akselsson, 2011, Jacobsson, Ek, & Akselsson, 2012Lindberg, Hansson, & Rollenhagen, 2010 ). However, many incident reporting systems are criticised for failing to collect information that supports incident prevention ( Dekker, 2007 ). The control structure model indicates that for antidoping organisations to learn from incidents, a systems-thinking based incident reporting and learning system that looks 'up and out' at the broader system rather than 'down and in' at individual wrong doing may be required ( Goode, Salmon, Lenne, & Finch, 2018 ). ...
Doping remains an intractable issue in sport and occurs in a complex and dynamic environment comprising interactions between individual, situational, and environmental factors. Anti-doping efforts have previously predominantly focused on athlete behaviours and sophisticated detection methods, however, doping issues remain. As such, there is merit in exploring an alternative approach. The aim of this study was to apply a systems thinking approach to model the current anti-doping system for four football codes in Australia, using the Systems Theoretic Accident Model and Processes (STAMP). The STAMP control structure was developed and validated by eighteen subject matter experts across a five-phase validation process. Within the developed model, education was identified as a prominent approach anti-doping authorities use to combat doping. Further, the model suggests that a majority of existing controls are reactive, and hence that there is potential to employ leading indicators to proactively prevent doping and that new incident reporting systems could be developed to capture such information. It is our contention that anti-doping research and practice should consider a shift away from the current reactive and reductionist approach of detection and enforcement to a proactive and systemic approach focused on leading indicators. This will provide anti-doping agencies a new lens to look at doping in sport.
... The IBOP spent time discussing the Just Culture approach to accountability, which changes how a regulatory boards approach discipline related to medication errors . 12 Specifically, patient safety is addressed in a manner where staff feels more safe in discussing, reporting, and acting on errors or mistakes. 13 Medication errors are treated as a system issue rather than an individual failure , and as such, rather than pursue a punitive approach to discipline against a licensee, the culture is oriented to learning from failures to improve future outcomes. ...
Boards of pharmacy have the authority to discipline licensees whose actions fall short of practice standards. Disciplinary action may include license suspension, revocation, practice restrictions, fines and reprimands. Once discipline is levied against a board of pharmacy licensee, it is usually part of the licensee’s permanent record. At least four states have created a pathway for individuals to seek expungement of previous disciplinary actions levied by a board of pharmacy. These states have variations on what violations may be expunged and when. Given the evolving approach to the regulation of pharmacists, more states may want to consider expungement pathways in the years ahead.
... Dekker stated that the model has a static view of the organisation and this leads to the idea of linear accident causality. He argued that presupposition of e.g. an independent subsystem and linearity of causes may influence safety management only to improve the quality of components while failing to consider the system as a whole (Dekker, 2007). ...
A comparison of two Systemic Accident Investigation Models when applied to a complex serious incident
Restorative just culture in healthcare is a dynamic process aimed at understanding the components of medical errors while recognizing the system failures that led to the incident and the effect on the patient, caregivers, and the community. It is a unique process because of the ability to look across the entire event, rather than focusing on one aspect (generally harm level). While many organizations have implemented a just culture, sometimes this has led to retributive culture where second victims are left with pain, suffering, and lack of communication. Restorative just culture aims to bring together all aspects of medical errors with inquiry, communication, and support for second victims. Understanding the differences between the two approaches allows complex healthcare organizations to evaluate their internal processes and develop better relationships with all involved parties.
Organizations, to comply with regulations and growing prosocial demands, develop robust accountability infrastructures : offices, techno-legal experts, programs, operating procedures, technologies, and tools dedicated to keeping the organization’s operations in line with regulations and external standards. Although an organization has a single, unified accountability infrastructure—one program, one set of policies and procedures, and so on for environmental management, or health and safety, or risk management—this infrastructure must produce compliance across a dynamic, complex organization. This happens when and because compliance managers and officers make a single, unified accountability infrastructure multiple and diverse in its day-to-day implementation. This approach to compliance work is pragmatic in the sense that rules and requirements are altered based on a deep understanding of regulatory expectations, local operations, and local work cultures. It depends on the skilled interpretation and adaptation of regulation and narration of compliance.
This introductory chapter combines several dimensions which are meant to help frame a complex topic representing a very rich diversity of situations across industries, countries, and epochs. The idea is to sensitize readers to several aspects associated with the topic of rules and autonomy in the domain of safety, and of this book. Its aim is to emphasize the importance of contexts when it comes to (safety) rules. Contexts refer to organizations, to industries, to risks, to histories, to practices, to situations, and to countries. Three sections develop the importance of context: (1) The advent of safety rules as an established narrative , (2) There is more than rules in safety , and (3) Historical trends … a bureaucratization of safety? The last section presents the chapters of this book, grouped in three categories, (1) Finding or losing the balance ; (2) The role, position, and influence of middle-managers and top management , finally; (3) When autonomy, initiative, and resilience take the lead .
The criminological study of corporate crime provides a source of insights into the key role of middle-managers in navigating the tensions between compliance-based and initiative-based approaches to safety. From an initial focus on individual and organizational motivations, the discipline has moved to highlight instead the influence of breakdowns in the connections between individual and organization. Three such grounds of disconnection (problems of ambiguity, structural uncoupling, and autonomy deficits) will be explored, and their implications for understandings of middle-managers’ role will be analyzed.
This study examines the impact of regulations and standard procedures on safety outcomes in unmanned aerial vehicle (UAV) operations, specifically focussing on Norwegian military UAV systems, from a high‐reliability organization (HRO) perspective. By analyzing data from existing regulations, accident reports, and interviews with military drone pilots using thematic analysis, we identify key recurring themes. Our findings highlight the importance of fatigue and exhaustion due to the absence of regulations on resting time for military drone pilots. This poses substantial risks and increases the likelihood of accidents and incidents in UAV operations. Additionally, we uncover gaps in safety reporting and accountability for military UAV pilots, indicating the need for improved reporting procedures that consider the unique operational elements of UAVs. Effective communication between stakeholders, including drone pilots, ground crew, and air traffic controllers, emerges as a critical factor in maintaining situational awareness. This emphasis on communication is consistent with HRO principles and supports the essential safety tasks of UAV pilots, namely sense‐making, decision making, and performance. By uncovering the impact of regulations and operational procedures on safety outcomes and addressing fatigue in UAV operations, this research contributes to enhancing the safety and reliability of Norwegian military UAV systems.
Este artigo parte do campo interdisciplinar de Fatores Humanos e busca apontar para as estratégias utilizadas por trabalhadores offshore da indústria de óleo e gás no decorrer das dinâmicas profissionais e pessoais. Considera-se, portanto, a relação entre essas estratégias e os contextos organizacionais, setoriais, cotidianos e de histórias de vida. A partir da perspectiva metodológica da pesquisa social interpretativa, realizou-se a análise reconstrutiva de 42 casos biográficos. As análises resultaram na construção de tipologias que identificam e descrevem elementos da cultura offshore tendo em vista a transformação dos processos relacionados à segurança operacional, mas também a temáticas como o exercício da liderança, investigações de acidentes e fatores interpretados como protetivos pelos trabalhadores. Palavras-chave: Cultura organizacional; Pesquisa Biográfica; Sociologia Interpretativa; Indústria de óleo e gás; Setor Offshore.
This chapter discusses how construction organisations can nurture the occupational health and well‐being (OHW) of their people and break through the safety performance plateau. It draws on the findings of two research projects investigating the culture and digitalisation of OHW and safety in the UK construction industry. The chapter explores how OHW can be embedded in construction practices from the perspective of structuration theory. It contributes to project organising studies by explicating how and why the current OHW practices fail and by providing a strategic approach that can help embed OHW in practices and, hence, improve organisational performance. Strategic investment in management capability is a key driver to incrementally transforming practices. Social capital entails networks of relationships that include norms, values, and obligations, which needs investment in relationships. The transactional business model needs change to incrementally invest in organisational capabilities to develop social and human capital.
The changing doctor-patient relationship and commercialization of modern medical practice has affected the practice of medicine. On the one hand, there can be unfavorable results of treatment and on the other hand the patient suspects negligence as a cause of their suffering. There is an increasing trend of medical litigation by unsatisfied patients. The Supreme Court has laid down guidelines for the criminal prosecution of a doctor. This has decreased the unnecessary harassment of doctors. As the medical profession has been brought under the provisions of the Consumer Protection Act, 1986, the patients have an easy method of litigation. There should be legal awareness among the doctors that will help them in the proper recording of medical management details. This will help them in defending their case during any allegation of medical negligence.
What is behind the medical malpractice crisis? What legal reforms would alleviate the crisis? What can you do to prevent litigation? What do you do when you have been sued? Are there alternatives to the current system? How does the medical malpractice insurance industry function? In Medical Malpractice: A Physician's Sourcebook, a panel of physicians, attorneys, academics, researchers, and insurance industry experts consider these and other questions about the origin, nature, and ramifications of the medical malpractice litigation crisis, as well as possible solutions and alternatives to the current system. The authors focus on the clinical face of litigation from the perspective of the practicing physician in a variety of specialties, ranging from family and emergency medicine to anesthesiology, obstetrics, gynecology, and plastic surgery. Special consideration is given to breast cancer and Pap smear litigation, risk management for the family physician, and the importance of effective patient communication. Additional legal chapters examine the litigation process itself, offering insight into winning medical malpractice lawsuits, the role of the physician as expert witness or defendant, the process of discovery and deposition, and how a plaintiff's attorney views risk reduction. Public policy experts argue the case for legal reform, suggest changes in medical-legal jurisprudence that can be of immediate benefit, and reflect on the broader problems of our entire health care system and its interface with law and social policy.
Authoritative and wide-ranging, Medical Malpractice: A Physician's Sourcebook gets to the heart of issues facing physicians and surgeons today. It focuses on the practical aspects of medical malpractice lawsuits, and prepares physicians and surgeons to participate in the public policy debate by addressing current topics that will help them understand the crisis, the threat to healthcare access, and the possibilities for legal reform.