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Just Culture principles applied to contract management

Just Culture Principles Applied to Contract Management, presented at CHC Safety & Quality Summit 2014

Fernando Moraes

on 2 October 2017

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Transcript of Just Culture principles applied to contract management

"Readiness of the psyche to act or react in a certain way" (Jung, 1921)
A Strong Safety Culture is
Information supports departmental interests
"Leadership shapes culture through different emphases on how to treat information"
Personal experience and observation
Emotional, behavioral and cognitive components
Scott Griffith
"Just Culture refers to a values-supportive model of
shared accountability
The just culture "contract"
As long as you choose to comply with the prescribed processes, you are not accountable for their outcomes.
Anytime that you choose not to comply, you will be held accountable, no matter the outcome.
If for your choice you lacked awareness of the risk, you will be coached, so that risk awareness is restored
Accepting human error but punishing violations
We will "teach them a lesson" without jeopardizing safety
The no-blame approach can't fix it all every time
Through shared accountability
We will pursue a better system design, wherein people will make better choices
Culture: an "after the fact" explanation for shared attitudes observed in a group
Cultural change: cause or consequence of changed attitudes?
Ron Westrum, "Leadership and Information Flow", 2006
Information supports the mission
Safety Culture
imply "knowing safety stuff"
Why not simply "safe culture"...
Just Culture
What is the point?
"What to do with who messes up ?"
"How to inspire the shared attitudes required to achieve success?"
Five Skills
David Marx
3 Duties
3 Behaviors
"How" and
That's "why"
“Just Culture” is the system we use to implement organizational improvement, presenting a set of design laws that influence our ability to create the societal outcomes we desire.
In a just culture there can also be punishment
The Leader's way
The "bossy" way
Just Culture process
The organization collects and analyzes relevant data to stay informed of its safety performance
People are confident they can report safety concerns without fear of blame
The organization learns from its mistakes and makes changes to unsafe conditions
The organization is able to reconfigure the chain of command if faced by a dynamic and demanding task environment
Shared attitudes
Our company has designed the processes in our system. Therefore, the company is accountable for their outcomes.
Just Culture is not leadership rehab
Steve Walters
"... I suppose in many respects the universe is a cruel, unyielding place because it only knows how to respond to the laws of physics embedded in it -
the laws of gravity and motion don't respond to good intentions
"Our job is to ruthlessly track down the blocks in the Zotov Error map before the map runs to its conclusion".
"Now, it would be nice to

do this with everyone's cooperation

in an environment of love, light and caring,

but this is

not a necessary prerequisite

when rolling dice with the gods of death and disaster".
"It’s a culture that holds
organizations accountable for the systems they design
and for how they respond to staff behaviors in fair and just manners".
What is the most fundamental requirement for a just -or any -culture?
Human factors
All factors that can make humans perform differently from machines
(From a system design perspective)
Donald Berwick
“The first law of improvement is that every system is perfectly designed to achieve exactly the results it gets"
Design choices
Unless you're a psychic, you need this
Open channels do not necessarily mean great channels
Lessons are not truly learned until embedded into the system
A critical attribute for resilience
"The choices we
make dictate the life we lead"

William Shakespeare
What can happen when humans fail to perform as machines, in a system where human work has been a design choice?
"just culture, baby!"
Human work is an unlikely design choice when, for a specific desired performance, full automation seems to be more profitable
No humans in here!
Human factors
Not an excuse for bad system design!
And yet...
The source of common behaviors
Talking about any culture, expecting to change attitudes, is like talking about the weather, expecting to change the ambient temperature
People understand the boundary between behaviors considered acceptable and unacceptable
Unacceptable behaviors are dealt with in a consistent, just and fair manner
Why does "Just" get so much more attention?
Is that all?
Commitment with what works
...while discarding what doesn't
Fostering the desired attitudes
Removing incentives for undesired attitudes
Punishing people for human error
It is:
Human factors as an universal excuse
...or "safety-supportive culture"?
Based on OGP Report 452 and on James Reason, 1998
"In turn,
staff are accountable for the quality of their choices
and for reporting both their errors and system vulnerabilities".
criminal Justice
Restore the balance
Just culture
Success through choices
Key limitation
Can't inspire the pursuit of excellence
What if lacking the skills to conduct a "Sully-style" ditching of an airliner in became a criminal offense?

Any chance of improving flight safety???
Key limitation
Mismatch with societal expectations on justice, although responding to choices can be harsher than criminal justice
2 restrained helpless victims
The Russian roulette paradox
"No list of errors, no matter how diligently memorized, can make you into a fine writer"
(Paul Brians, "Common Errors in English Usage")
To what extent would a drunk pilot be playing "Russian roulette" with his passengers, his crew and bystanders at the crash site?
We can only wish to master incentives as video game developers do,
for people who voluntarily paid to play
Incentives in Batman Arkham Origins (PS3)
Not being hit during a round
Not being hit during all rounds
Hitting a enemy with every attack, sequentially
Timing attacks perfectly within each sequence
Varying through all available attacks in a round
Achieving defined scores through 3 levels
Achieving the highest scores in the world
Succeeding in all different challenges in the game
Trophys or
point multipliers for
Reduction of life
Loss of points multiplier
Reduction of the lethality of attacks
Loss of earned special combo moves
Multiplication of enemies
Defeat in round and match if life is depleted
Setbacks (punishments?)
USA criminal justice system flowchart
The best case scenario that can be achieved through the expectation of punishment is
Compliance alone does not ensure
Rematch at will from the previously saved state
a quest for balance
If human error results from the human condition
What's the deal with "fair" and "just"?
And punishment does not change the human condition
Then punishment will not reduce human error
If undesired outcomes may result from human errors and choices
And the expectation of punishment can deter unacceptable choices
Then the complete absence of punishment may lead to undesired outcomes
About Leadership
All you need to know:
Jens Rasmussen
"Accidents are ... the effect of a systematic migration of organizational behavior under the influence of pressure toward cost-effectiveness in an aggressive, competitive environment".
Information supports the power and glory of individuals
The duty to avoid causing unjustified risk or harm
The duty to produce an outcome
The duty to follow a procedural rule
Being on time for work
Honoring your word
Compliance with speed limits
Passengers at the correct destination on time
OEM approved maintenance
Prescriptive customer requirements
SOP`s, checklists
Do no harm
Voluntary reporting
Captain`s ultimate authority to ensure a safe flight
STOP programs
Client expectations
System owner expectations
Societal expectations
Shared accountability
2 criminals play 1 round of Russian roulette on each victim
Only 1 victim is shot and dies
Police arrests both criminals
Criminal Justice response?
"Just Culture" response?
Do the odds matter?

Success through choices
More incentives for the desired choices
Desired attitudes
Less incentives for the undesired choices
Mastering Incentives
Tougher than it may seem...

Agreed duties between parties that exchange deliverables and payments

same principles may apply
Responding to expectations
Responding to attitudes
Responding to choices
Responding to outcomes
Right choices
the easier choices
Theory into best practice: PEOTRAM
Great system design can reduce the demand for punishment, by making the right choices the easier choices.
The outcomes of human error are owned by whoever made the design choices that included humans as system components
"Just" is only one of the attributes required for an organizational culture to be safe
No need to be a fearless moral giant to "do the right thing"
Yearly audit and evaluation based on OGP standards and industry best practice
Full transcript