“When a safety event occurs, like a mishap, accident or near accident, it is often obvious what went wrong. With hindsight, it is all too easy to point to a certain person that made a mistake, an error of judgement, or violated rules. Quite often, this is not true. Nobody goes to work with the intention to make a mistake. But having blamed somebody for the event, the true failures in the system will not be laid bare, which are often wrong procedures for the task, ill-defined responsibilities or managerial flaws. The effect is that further safety improvement is no longer possible or even frustrated, particularly when events are being criminally prosecuted. The conditions for the safety event remain until the dice are rolled again and another person finds himself in the same situation.”
(Kools and Brüggen, 2013)
This Blog captures First Stories. The news headlines. Soundbites that sell newspapers or attracts people’s attention with the promise of a dramatic revelation. But it also delivers the second story. The why behind the “human error’. The real reason why things went wrong and the key to learning how to make things better. If you are unfamiliar with Just Culture and systems thinking, have a look at this masters thesis:
If you like to get in touch to discuss Just Culture or other safety-relevant topics, just reach out to me via LinkedIn. I would love to hear your views!
* Roderick van Dam, EUROCONTROL Just Culture Task Force