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Abstract
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Just culture.
In just culture Dekker makes the case for a culture where after an incident people can speak out about their ideas, their recollections, their memories and reconstructions without fear of retaliation. A just culture is the opposite of a culture where all human error is converted into a crime, where people are ruthlessly held accountable for all their deeds, including verbal statements. The ruthlessly accountable culture is the one we like so much in crime series on television. Here, the police and public prosecutor stand for justice to be done and they speak on behalf of the people. In 13 short chapters Dekker gradually builds his case: between culpable and blameless; the importance of reporting; hindsight and determining culpability; are judicial proceedings bad for safety?; stakeholders in the legal pursuit of justice; without prosecutors there would be no crime, to name a few. His arguments come mostly from cases where people have made errors that led to serious incidents. The majority of these cases are from the health care industry and aviation sector. His arguments are predominantly practical psychological in nature with some from an ethical or epistemological perspective. He discusses and discards decision trees for determining culpability because the hindsight stories are inevitably distorted and contaminated with knowledge of the (dramatic) outcome. In essence, search for a just culture boils down to answering three questions: (1) who in the organisation gets to draw the line between acceptable and unacceptable behaviour; (2) what and where should the role of domain expertise be in judging whether behaviour is acceptable or unacceptable; and (3) how to protect safety data against judicial interference. In summary, he lays out the choice between the old view, where human error is the cause of incidents and hence should be treated against the new ‘systems’ view where human error is seen as a symptom rather than a cause and a systems perspective is taken to improve things. The latter is preferred but this does not answer the three questions. Then we inevitably enter the field of ethics. The final chapter sketches a four step approach to building the desired just culture and in the epilogue Dekker says openly he does not believe Aristotelian justice in courts for human error, because it will always produce more lies and losers.
Field guide to understanding human error.
The field guide to understanding human error could be seen as a complement to the just culture book. This book puts the bad apple theory against the new view of human error. The former is the ‘traditional’ view where human error is seen as the cause of accidents and hence the endpoint of an accident investigation. The alternative is the ‘systems’ view where accidents are caused by system errors which emerge through human error. Human error is thus the starting point for an investigation. In 21 chapters Dekker gives a tour d’horizon of the field of accident investigation – the (numerous) pitfalls, the possibilities and impossibilities – and so he sketches the techniques for collecting and analysing data. He highlights unpleasant questions like the influence of the accident model on the outcome, the fact that an investigation is a way of defining the truth. He discusses how to interview (‘debrief’) people involved, the benefits of a timeline; the need to leave an investigation trail during the analysis; diagnosing the ‘real’ causes in a highly complex and highly proceduralised world and the art of providing recommendations. The penultimate chapter is about individual responsibility, the difference between holding people accountable and asking them for their account. The final chapter is dedicated to make the safety department leading in a transition process to the new view.
Both books are well written and interested general safety professionals will read thrilling stories, learn at a high level about concepts and techniques in the field. However, although noble and sympathetic, I doubt whether these books will convince many ‘enemies’: adherents of the (easy) ‘old view’; the scientific skeptics or people with a legal mindset on accidents. |