Creating a Culture for LearningChapter 3

Objectives• Describe how to create a just culture.• Describe the practice of placing blame.• Describe the danger of complacency.• Describe how to reestablish trust with

the public after a negative incident.• Describe the role of self-reporting and

trend files in creating a just culture.

A Stronger Foundation for CRM: Establishing a Just Culture (1 of 2)

• Implementing CRM requires building a solid organizational culture. – Organizational stories can negatively affect

communication by preventing individuals from speaking out.

A Stronger Foundation for CRM: Establishing a Just Culture (2 of 2)

• Introducing and embracing new methods of understanding human error builds an open communication culture. – Placing individual blame hides the real source

of error and drives errors and mistakes underground.

– No individual will self-report a mistake for fear of repercussions.

– Create an intentional, just, and learning culture.

Placing Blame (1 of 3)

• Placing blame is understandable. – Social norms are biased toward holding someone

responsible. – Disturbing trend of criminalizing human errors

made during complex events– After facts are known, it is easy to see whether a

decision point led to the accident– Organizations (and the public) believe everything

should be under the operator’s control.

Placing Blame (2 of 3)

• Different types of jobs but same expectations for error-free work – Can different types of work be evaluated in

the same way? – Can individuals or teams be expected to

perform flawlessly within dynamic, changing, personally dangerous, and complex environments?

– Clarity in action comes retrospectively.

Placing Blame (3 of 3)

• What is an acceptable error rate? – When errors are made, what are the

individual and organizational responsibilities for making things right?

What Is a Just Culture? (1 of 6)

• People investigating a bad outcome want the truth. – Truth is the entire story associated with an event:

• Decisions made• Environment in which the decisions were made• Organizational culture• Tools at hand• Education and its limits• Knowledge of the situation• Experience

What Is a Just Culture? (2 of 6)

• Everyone makes mistakes. – How do organizations maintain public trust, take

responsibility for errors, sustain an open environment, and yet still protect themselves from being sued or ruined?

– Develop a resilient, open, just culture that:• Allows error• Analyzes behavior and its effects• Performs critiques after good and bad outcomes • Takes responsibility for mistakes

What Is a Just Culture? (3 of 6)

• There are many perspectives on what constitutes a just culture.– Team leaders create a just culture by

exchanging anger for fairness and explanation.

What Is a Just Culture? (4 of 6)

• Leaders must hold individuals accountable for purposeful, intentionally bad behavior. – Overlooking or ignoring sabotage and disregard

makes employees who follow rules, learn, and play fair resentful.

– Reputations are built on many actions and lost through only one.

– Individuals find it difficult to maintain a positive outlook and culture when few “undo” the positive contributions of many.

What Is a Just Culture? (5 of 6)

• A just culture is important to building an atmosphere that allows for open communication.– Just culture includes forgiveness and

understanding and corrective action and accountability.

– Accountability is the act of taking responsibility and being answerable and blameworthy for actions taken with the expectation of being called to account.

What Is a Just Culture? (6 of 6)

• What is accountability?– The public needs to know whether organizations

understand the consequences of their mistakes. – Directly related to learning from a mistake

• Answer questions.• Gather information.• Seek outside expertise.• Bring in impartial members of the public.• Explain that you are doing all you can.

Complacency Kills (1 of 5)

• New York Times reporter is killed by complacency.

• Occurs when an organization’s mission is unclear or not reinforced and normalization of deviance develops– Normalization of deviance: a lower

standard of performance is accepted until the lower standard becomes the norm

Complacency Kills (2 of 5)

• Team or individual perceives it is too difficult to adhere to a higher standard when system stresses are present. – Underperforming behavior becomes the norm after

the stress passes or more resources are available. – Normalization of deviance is not an individual

problem or a behavioral attribute that causes people to take actions that are purposefully harmful.

Complacency Kills (3 of 5)

• One of the first steps in resolving normalization of deviance is to develop a more comprehensive outlook of the situation.– Taking a systematic and fair approach– Fostering open communication

Complacency Kills (4 of 5)

• Deviations from protocol– To determine the causes of complacency, leaders

must discover systemic issues that factored in decision making.

– Crew’s decision to interpret the Rosenbaum situation as low severity may have been a complacent response

– Individual who is part of a team using an effective communication model offers protection against complacency

Complacency Kills (5 of 5)

• Deviations from protocol (continued)– Stories become a cultural barrier against

taking action.– Veteran’s bias: younger team members are

influenced to deviate from protocol or standards by veteran crew members

Establishing and Losing Trust (1 of 8)

• After the Rosenbaum incident was analyzed, causal factors became fairly well understood. – Many system changes were necessary. – When organizations harm someone, they

owe a settlement to acknowledge the loss and help with future hardship.

– Response lets organizations build trust

Establishing and Losing Trust (2 of 8)

• Public trust could have been established if the agency had issued a response accepting the responsibility for the undesired outcome, promising to make an effort to understand human errors.

• Cases validate a just culture but usually are opportunities lost.

Establishing and Losing Trust (3 of 8)

• The right reaction: taking responsibility– Admitting an error should be a nonpunitive

event within a system. – Personnel must know that revealing errors is

paramount to the learning process and future safety of the organization.

– A just culture determines the cause for failure that satisfies the demand for accountability and the need for learning and improvement.

Establishing and Losing Trust (4 of 8)

• CRM will take hold in an organization if the environment makes individuals:– Do the right thing– Speak up when they see problems– Commit to continual improvement

• Postincident analysis– Proves that no single account is the one

true story of what happened

Establishing and Losing Trust (5 of 8)

• Systemic cause analysis– Teams evaluate actions in the context of the

entirety.• The culture• The specific situation• Personnel training• Experience levels

– SCA begins with asking each person involved to write down his or her perceptions of the incident.

Establishing and Losing Trust (6 of 8)

• Ask individuals involved to write a narrative, then separate their decisions and influences into categories:– Systemic influences– Education and training failures– Circumstances beyond the operator’s control– Human factor influences

• Team leaders may provide a list as an example.

Establishing and Losing Trust (7 of 8)

• There will be inconsistencies in people’s stories.

• Once the appropriate information is gathered, build an incident timeline.

• Basic rules of SCA:– Make sure the right people are on the analysis

team.– Gather all relevant facts associated with the

incident.

Establishing and Losing Trust (8 of 8)

• Basic rules of SCA (continued):– Team leaders should develop, introduce,

and follow basic ground rules.– Organizations must commit procedures to

writing that everyone can understand.– Making the process transparent helps build

credibility and provides critical support to leaders and policymakers.

An Important Piece: Self-Reporting and Trend Files (1 of 4)

• Create a method for individuals to self-report errors and near misses. – A near miss describes a “near hit.” – Something that almost caused a serious

accident or injury but did not

An Important Piece: Self-Reporting and Trend Files (2 of 4)

• Best practices for developing self-reporting systems:– Forms are completed and submitted

anonymously.– Forms use standardized questions that

collect key information.– Forms create a database for grouping key

information into “trend files.”

An Important Piece: Self-Reporting and Trend Files (3 of 4)

• Trend files are lists that include potential accident causes, training issues, equipment issues, and other factors that can be mined from the database.

• Risk managers and performance management teams may set specific performance thresholds for certain errors.

An Important Piece: Self-Reporting and Trend Files (4 of 4)

• Near-miss databases and trend files contribute to the learning organization, empower employees to be risk managers and seek out potential failure points, and reinforce nonpunitive systematic error analysis. – Front-line operators know the information they

contribute will help others avoid the same mistakes.

Why Develop a Learning Culture? (1 of 3)

• Pressure is placed on the leaders of organizations when something goes wrong. – People want answers, quickly. – Media jumps to conclusions, places blame,

and has to get the story out now.

Why Develop a Learning Culture? (2 of 3)

• Agencies that want to develop a learning culture use openness, clarity, and honesty. – Educate policymakers about conducting SCA,

fostering just culture, and facilitating nonpunitive self-reporting of error.

– When they are educated about CRM, there is less pressure on the leader and employees when something goes wrong.

Why Develop a Learning Culture? (3 of 3)

• Public receives honest and straightforward feedback from leaders and policymakers.

• An organization can introduce CRM principles with ease. – Open communication, direct and honest

feedback, and collective problem solving are part of the organizational fabric.

Summary (1 of 2)

• Individuals and teams working in highly dynamic environments with danger and uncertainty must make decisions when only some information is available.

• Clarity in actions comes retrospectively.• Accountability is related to organizational

and individual steps taken to learn from a mistake.

Summary (2 of 2)

• For a just culture to work, employees must know that revealing an error is paramount to the learning and safety of an organization and others.

• CRM requires an environment where individuals feel responsible to do the right thing, speak up when seeing problem, and commit themselves to continual improvement.