Just Culture / No Blame Environment for More Effective Investigations Establishing a Just Culture / No Blame Environment for More Effective Investigations Jim Whiting Principal Risk Engineer & MD risk@workplaces pty ltd, Australia jim@workplaces.com.au Blame / Accountability / Just Culture Group Exercise

A ray of hope? Article scanned from “The Age” Melbourne 28 April 1999 Photo ABC News website

Value people because they are people (not resources). In business-speak, people are referred to as “resources” Resource: an item deployed to achieve an end. If we continue to call them “human resources” we will never think of them as people. Photo by Permission of Peter Jarver

A ) See below some examples of “common” spoken or written expressions ( Used in ALL aspects of our lives - not just our work experiences ! ) which we often use to indicate blame after and before incidents / accidents. Examples :- 1) Who did it ? Someone is going to pay for this 2) Whose to blame ? / Who was at fault ? 3) Whose shift / roster was it ? Which contractor ? 4) Who can we sue for this ? – It wasn’t my fault ! 5) Who can we blame / hang / sack / fire ....... for this ? 6) If there is any kind of stuff-up / goof-up, you’re going to pay for it ! 7) What an idiot ! That’s common-sense ! He/She is a qualified .... 8) He/She is accident-prone ! He takes risks he shouldn’t . 9) YOU have a serious accident in YOUR area and you are .....!! 10) A “hero” takes risks other ‘normal’ people wouldn’t Brainstorm (with your group) to suggest some more from your own experiences 11)...................................................................................... 12)...................................................................................... 13)......................................................................................

B) Which of the expressions in A) are Reasonable ? Acceptable ? in your organisational culture ?……………………………………………… C) i) What are the differences between blame and accountability ? ......................................................................................................... ii) If you are given a responsibility to fulfill ( i.e. a job to do ) and you agree that you have been given adequate au………….? to do it , is it fair and reasonable for you then to be held accountable if you don’t fulfill the responsibility ? Keep these 3 words together D) i) Can an organisation have accountability without blame ? ii) Is unfair accountability really nothing else but blame?............................... E) i) Can the expressions “no blame” or “blame-free culture” be wrongly taken by some employees as meaning “no discipline” ? …………………………. ii) Which of the expressions:- “no blame culture” or “blame-free culture” or “fair culture” or “just culture” or “ accountability without blame” is best for you …..?

Would you say your company’s response to incidents is mainly F) Would you say your company’s response to incidents is mainly punitive ? or learning ? G) What are the differences between“ error” /“intentional rule violation”? ii) When does behaviour become “reckless conduct” ? or “negligent conduct” ? iii ) After an accident involving any combination of the 4 behaviors above, what is the appropriate disciplinary response ( if any ) to each of the 4 ? …………… iv) what happens in most organisations ? …………………………………… v) Is an error a consequence or a cause ?……………………………………… H) How many adjectives are used in front of the word “cause” ? Can we use less of them ? root, contributory, main, only, significant, proximate, immediate, active, latent, systemic.... I) How is all the above relevant to :- “ incident investigation ” and “ problem solving ” ? For a copy of PowerPoint - contact Jim Whiting jim@workplaces.com.au