1. Just Culture
making it work
Job Brüggen

3. Questions What IS a Just Culture? Who needs a Just Culture?
Why do WE need a Just Culture?
Who is busy with a Just Culture?
How to make and guard a Just Culture?
Is there a law on Just Culture?
What can WE do for Just Culture?

4. What is a Just Culture?
A culture in which frontline operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.“

6. Who needs a Just Culture?
They are humans
Humans make mistakes
If we want these people to perform these jobs…
…we must find a way of dealing fairly and justly with these inevitable errors.

7. Linear model of failure

8. Why do we need a Just Culture?
Where FEAR is leading, people will not learn to improve, but people will learn not to get caught.
Learning is safer than punishing!

9. Pro-active learning : ROLES
Managers
Workforce
Installing trust
Risk Awareness
Design for safety
Facilitate the right choice
Effective learning from events
Earning Trust
Risk awareness
Design for safety
Reporting
Learning
Being a role model

10. Just Culture background material
Sidney Dekker. Just Culture. Balancing Safety and Accountability. Amazon
Hearts and Minds available at the Energy Institute
GAIN [Global Aviation Information network] A Roadmap to a Just Culture. Enhancing the Safety Environment. 
Baines & Simmons. FAiR® System (Flowchart Analysis of Investigation Results)
Reason. Managing Risks of Organizational Accidents.Amazon.
Reason. Human error: models and management. 
Hudson. A new model for a Just and Fair Culture.
Hudson. Safety Culture – Theory and Practice
Eurocontrol Skybrary - Link to Just Culture material
Eurocontrol. Establishment of Just Culture principles in ATM safety data reporting and assessment.
Mateou. Flying in the Face of Criminalization. The Safety Implications of Prosecuting Aviation Professionals for Accidents
David Marx. Whack a mole. The price we pay for expecting perfection.
Eurocontrol. Just Culture Guidance Material for Interfacing with the Judicial System
European Commission: EU REG 2003/42
European Commission: update
ICAO Safety Of Information Protection TaskForce
Eurocontrol Just Culture Policy

11. How to create a Just Culture?
Policy
What you want to achieve: a learning culture.
Better one lesson learned, then ten people punished.
Definitions :
What is good behaviour
What is bad behaviour
What you will do with BOTH
Procedures
Define WHO gets to say what is right and wrong
Involve the workforce!
Show good leadership
Lead by example: it is NOT only about the workforce

13. Tools to help classify behavior
Flavors:
Crude
Old
Complex
Useful

14. David Marx-Just Culture Community

15. David Marx-Just Culture Community

18. Baines & Simmons

19. Baines and Simmons

21. Hearts and Minds

22. Hearts and Minds

23. ICAO

24. Eurocontrol Just Culture Task Force
Just Culture Model Policy
Coordination Just Culture and related activities:
In Europe with EU, EASA, ECAC
In ICAO and global regions
Model for a National Aviation Prosecution Policy
To be discussed and implemented at National or Regional level
Support to the Judiciary:
Dedicated experts course for assisting Judiciary
European initiatives for establishing a dialogue between safety and judicial experts

25. Netherlands’ law Implemented EU Directive on Aviation Reporting
Includes protection for reporters
Restrictions for prosecutor
Willful misconduct and gross negligence excluded!

26. Now, what can WE do?
We shall start with OURSELVES

27. SOCIETY
service
service
Safety
rights
Justice
rights
beliefs
beliefs

28. Internal Just Culture first
Give people trust so they action their good intentions over and above their emotions.
Better safety performance
Your Just Culture adopts already parts of the classical beliefs of criminal justice.
Justice officers will better trust your system
A good INTERNAL Just Culture assists a good EXTERNAL Just Culture

29. Easy cases are … well, easy.UP
WINGS
FALL OFF
STOP
WINGS
STAY ON
DOWN
SEAT RECLINE SWITCH
Honest mistake
Reckless behavior
…but where is the real line between honest mistake and culpable behavior?

30. Interpreting human behavior
“The line” is drawn in 256 shades of gray!
INTENT is what counts, not the outcome
Reward and stimulate positive behavior
What about the (non-)actions of the manager?

31.
Sharing practical experience handling (internal) Just Culture issues
Multiple fields
Healthcare
Processindustry
Aviation
Interactive
Smartphone-ready (Just Culture in your pocket!)
Expansions to Inspection, Prosecutor roles (future)

32. The background Based on JC “models” and theory Synthesis James Reason
David Marx
Baines & Simmons
Hearts & Minds
Sidney Dekker
Synthesis
Avoid too simplistic views
Take out overcomplicated theories
Emphasize the positive side
Include the management

33. Navigator

34. The website

35. Just Culture in your Pocket
firstaid.safetyandjustice.eu

36. Now what is your status? Fallen asleep
Stayed awake but did not understand
Yeah interesting, thanks
I am going to do something with it.