martin ralph - ifap - no blame culture: reality or myth?

JUST Cultures and Safety?

Safety in Action Conference

Perth, 11th – 12th June 2014Martin I Ralph

Managing Director

• Playing Cassandra

• A Couple of Lessons from Psychology

• What do we mean by a JUST Culture?

• The Emerging Science of Intentions

• Does it Matter? – Prospect Theory

• The Impact of Our Language

• Creating a Culture of Safety

• The Hope...

Presentation Outline

Safety In Action 2© Copyright IFAP: 2014

ABS Adult Literacy and Life Skills Survey (2006):

A score of 3 is considered to be the minimum level to meet the complex demands

of everyday life.

• 10.6 million (70%) Australians scored a 1 or 2 for Problem Solving;

Insufficient planning and reasoning abilities

71% of WA males scored 1 or 2.

• 47% of Australians at Level 1 or 2 in Document literacy;

• 53% of Australians at Level 1 or 2 for Numeracy;

WA males 47%, females 55%

Source: Stats Talk WA, June 2010 1304.5 www.abs.gov.au

Playing Cassandra

© Copyright

IFAP: 2014© Copyright IFAP: 2014 Safety In Action

Those in the safety promotion field have to understand that it’s likely that of the

people in our “audience” :

• 50% can’t correctly read or interpret the documents we provide;

• 50% won’t be able to appropriately process numeric information we supply;

and

• ⅔rds wont be able to solve a moderately difficult problem.

So the emphasis is on us to simplify our message while making sure the

manner in which it is “broadcast” aids interpretation.

Surely?

What does this mean?

© Copyright

IFAP: 2014© Copyright IFAP: 2014 Safety In Action

For What I Am About To Do ...


Why Do We Blame?

• One of the underpinning tenets of psychology. Humans tend to behave in a

manner that:

gains what we want; or

gets rid of what we don’t want.

• Blame has negative connotations;

It is frequently something that people do not want to be associated with.

• And because none of us like to be blamed – if our actions did contribute we

tend to say that something / one else 'forced' our behaviour:

The fundamental attribution error.

Lesson From Psychology (1)


The Fundamental Attribution Error:

• The struggle to explain the action of others.

When evaluating other people we tend to overestimate the power of internal

influences and underestimate external influences.

» eg an accident victim may be characterised as stupid or careless,

» instead of being undertrained or a casualty of a poor system.

When we evaluate ourselves we are apt to blame external factors rather than our

internal factors

» usually blaming our bad luck.

This is a critical, but all too common failing when it comes to Accident

Investigation and Analysis.

Lesson From Psychology (2)


Don’t think of the colour BLUE ….

• Statements such as 'we will not have a blame culture‘ are more likely to raise

the possibility of blame than remove it.

• You must know what blame is to be able to remove it from the culture!

Blame Cultures are Self-Reinforcing


International Council on Mining and Metals, April 2013:

• Emergent Theme 2.2.4

• “From a culture of blame to one of care, ownership and accountability ...”

The underlying principle is that if health and safety are related to the well-being of

people, then a safe culture is one that is rooted in building relationships based on

trust, out of genuine care for people…

This requires that blame cultures are replaced by ones that allow open discussions of

what went wrong to enable learning…

Source: ICMM Report on 2012 Health and Safety Conference, April 2013

A Contemporary Issue


An organisational culture that:

• Empowers employees to be responsible for making their own decisions

• Tolerates mistakes - providing that people learn from them.

Accepts that mistakes will happen – inevitably!

• Challenges behaviours that led to an accident, and not the person(s) involved.

• People become more responsible and are willing to be held accountable:

they know that they will be respected for who they are and what they can achieve,

rather than for any mistake they make along the way.

But the No Blame (Just) approach has also been criticised as not holding

anyone accountable for accidents.

• This view is certainly not supported from the psychology of safety approach ….

What Is a JUST Culture ?


Situational Analysis

Safety In Action

Individual Variance

No

At Risk Behaviour

Yes

Did the person purposefully perform

a behavior which they knew to be unsafe?

Human Error Risky Behaviour

System-Induced

Human Error

System-Encouraged

Behavior

Willful Negligence

Act of Sabotage

11© Copyright IFAP: 2014

• Willfull – Of action for which compulsion or ignorance or accident cannot be

pleaded as excuse; deliberate, intentional;Concise Oxford Dictionary

» “…an intentional act or omission to cause harmful and avoidable consequences”

" …a wanton or reckless act or omission as amounts to a willful and utter disregard for

the harmful and avoidable consequences of the act or omission (but not including any

errors of judgment, mistake or act or omission whether negligent or not, made in good

faith … )”http://www.mallesons.com/publications/2008/Dec/9711766w.htm

Willful Negligence / Default?


• You are about to see a short video clip, featuring German Chancellor Angela

Merkel;

She is in the city of Dremmin, Germany on the 4th April 2012 at the annual Ash

Wednesday commemoration;

She has had a hard fortnight. Germany had been supporting Europe’s recovery from

the Global Financial Crisis and had been locked in at-times-heated talks with the

Greek government on implementing austerity measures.

Your challenge – describe what happens in 10 words or less.

Willfulness ? Angela’s Example


Examples From Society 1 - Angela…


• What did you write down?

• I’m willing to wager something like …

The waiter spilled drinks on Angela.

6 words

Willfulness ? Angela’s Example


• Now you are about to see a short clip featuring Eric Williams, a journeyman

NBL (USA) basketballer and his wife Jen.

Their marriage has been shaky for some time;

August 2009, Eric invites Jen to meet in a romantic setting over dinner to “patch things

up”

Unbeknown to Eric, Jen has invited a film crew from the television show

“Basketballers’ Wives” to capture the moment;

Eric is not amused;

Your challenge – describe what happens in 10 words or less.

Willfulness ? Eric and Jen’s Example


Examples From Society 2 – Eric & Jen …


• What did you write down?

• I’m willing to wager something like …

Eric threw a drink at Jen.

6 words

Willfulness ? Eric & Jens’ Example


You be the Judge …


Situational Analysis

Safety In Action

Individual Variance

No

At Risk Behaviour

Yes

Did the person purposefully perform

a behavior which they knew to be unsafe?

Human Error Risky Behaviour

System-Induced

Human Error

System-Encouraged

Behavior

Willful Negligence

Act of Sabotage


An emerging field that makes use of empirical data to inform research on

philosophical questions.

• Uses surveys to probe the intuitions of ordinary people

Initially began by focusing on intentional actions.

• Like all new fields of endeavour, experimental philosophy has it’s critics,

however ...

• Growing into other areas (such as free will, language etc)

The power of the intentional action research has been best illustrated by scenes

called vignettes.

Here’s 2 straightforward ones from Joshua Knobe, University of North Carolina ...

Experimental Philosophy


Vignette 1


• A vice president of a large company goes to the CEO and says:

“We have a new business plan. It will make huge amounts of money for the

company, but it will also harm the environment”.

• The CEO says:

“I know the plan will harm the environment, but I don’t care about that, I’m just

interested in making as much money as we possibly can. So let’s put the plan

into action”...

• The company starts the plan, and the environment is harmed...

Joshua Knobe, University of North Carolina

Vignette 1 Recap:


Vignette 1


Vignette 2


• A vice president of a large company goes to the CEO and says:

“We have a new business plan. It will make huge amounts of money for the

company, but it will also help the environment”.

• The CEO says:

“I know the plan will help the environment, but I don’t care about that, I’m just

interested in making as much money as we possibly can. So let’s put the plan

into action”...

• The company starts the plan, and the environment is helped...

Joshua Knobe, University of North Carolina

Vignette 2 Recap:


Vignette 2


Experimental Philosophy

Safety In Action

The Knobe Effect:


• If we get success – it’s due to luck but not intentional;

• If we experience a bad outcome (an accident) – it’s intentional.

Brilliant coverage on: http://www.abc.net.au/rn/allinthemind/stories/2009/2493436.htm

What appears to be occurring is that we are making moral judgements

based on the outcome of the actions.

• Emotions (skewed by moral judgement) cloud the decision of whether an action

was done on purpose or not;

Psychology considers this as a pre-cognitive commitment...

Interim Summary


Imagine a rare disease is breaking out and is expected to kill 600 people.

Two different health interventions are available to deal with the threat:

a) Programme A: which if adopted, will save 200 of the 600 people; or

b) Programme B: which has a 33% probability of saving everyone, and a 67%

probability of saving no-one ?

Which programme would you choose (a) or (b) ?

• Both Programmes carry the same mathematical expectancy;

• Rational people should pick Programme A;

• In the experiments, 72% of subjects chose Programme A = risk averse.

Source: Against the Gods, Peter L Bernstein, 1998 Ch 16

Does it Really Matter #1 ?


Imagine a rare disease is breaking out and is expected to kill 600 people.

Two different health interventions are available to deal with the threat:

c) Programme C: which if adopted, 400 of the 600 people will die; or

d) Programme D: which has a 33% probability that no-one will die, and a 67%

probability that everyone will die?

Which programme would you choose (c) or (d) ?

• Again, both Programmes carry the same mathematical expectancy;

• Phrased in terms of deaths, 78% of subjects chose the gamble = risk seeking.

• They could not tolerate the prospect of the sure loss of 400 lives ….

Source: Against the Gods, Peter L Bernstein, 1998 Ch 16

Does it Really Matter #2 ?


Impact of Prospect Theory (Kahneman and Tversky 1979)

Tversky believes that:

“judgements are attached not to events, but to the description of events

… the judgement of an event depends upon the explicitness of it’s

description”.

Does it Really Matter ?


• Professor Kate Burridge (Linguistics, Monash University)

With apologies – the accident v incident debate revisited !

Incident (or occurrence) is a euphemism for accident;

A euphemism is a sweet sounding inoffensive alternative used, ...

to deliberately disguise a topic and to deceive..

“I cannot see the reason for those in OSH to give up on the word accident ...

Importantly where there is no strong implication of fault ...”

Source: Personal correspondence 1st December 2008

The Impact of Our Language


Concept: Language Shapes Thought Which Then Shapes Behaviour

• Ground-breaking research by Lera Boroditsky (University of California San Diego via Sanford University)

Language is a socially enforced and practical skill

Therefore it influences and is influenced by culture

• Languages differ in how they describe causal events:

English:

» She broke the cup ...;

Spanish or Japanese:

» The cup broke; or

» To her it happened that the cup broke ...;

• The difference is in the grammatical agent (she versus the cup).

Language, Thought and Blame


• English – very little difference between accidents and intentional actions.

• Spanish or Japanese - much higher differentiation.

• Lab experiments, videos of simple accidental events and intentional events;» Eg popping ballons or dropping (throwing) objects

• English speakers: - remembered equally well between accidents and intentions

Importantly, they remembered who was involved!

• Spanish or Japanese

remembered who was involved in intentional actions very well

but remembered who was involved in accidents poorly.

Question: Is Blame Culturally Reinforced by Our Language ?



Look back at your notes on the Angela and Eric and Jen examples:

Did your description name names? Was it agentive or non-agentive?

Question (again): Is Language a Cultural Reinforcer ?

Language, Thought and Culture


You are now about to see a video clip taken from the Oprah Winfrey Show

that highlights why defining intentions through agentive language is so

important to our social and legal frameworks....

• Super Bowl XXXVIII

• Carolina Panthers v New England Patriots

• Reliant Stadium, Houston Texas 1st February 2004

• Hailed by Sports Illustrated as the Greatest Super Bowl of all time

• Watched by 144.4 million viewers

• Patriots won 32-29



The Janet and Justin Scandal


Experimental Determinations, either:

1. Justin reached across and tore Janet’s outfit; (this is an agentive statement) or

2. Justin reached across and Janet’s outfit tore.

Subjects who saw the video and received the agentive description (#1)

Blamed Justin more; and

Wanted to fine him 53% more

than subjects who saw the video and received the non-agentive description.

Question: What Does This Say About the Language We Use and the

Outcomes We Can Achieve ?

More brilliant coverage on: http://www.abc.net.au/rn/allinthemind/stories/2012/

The Janet and Justin Scandal


A culture of safety = an informed culture which means eradicating Blame.

• A JUST Culture of Safety presents problems… because organisations must

refrain from resorting to blame as a first response:

which means intentions must be clarified (not pre-judged).

which is reliant on:

» the language we use, and the way we frame risk…

» demonstrating empathy with those unfortunate enough to be involved in accidents.

• Accepting that people make mistakes & more so when under pressure.

look out for Attribution Error fingerprints...

• Don’t rename blame and its euphemisms to something else to avoid the issue:

this is often sloppy thinking and leads to more rather than less problems.

Blame Culture Blues - How the Language of Blame Manifests Organisational Underperformance by Stuart Avery

Creating a JUST Culture of Safety


http://ezinearticles.com/?expert=Stuart_Avery

Blaze “an accident” 9/2/2011

Kelmscott residents who lost their homes say they have empathy for the man

under investigation for accidentally causing the bushfire with an angle grinder.

He wouldn’t have wanted that, it was “just an accident,” Sunset Terrace resident

Susan McWatters said.

It is understood the man may be charged….

Am I Dreaming? …


The Hope ...

Safety In Action

http://au.news.yahoo.com/thewest/galleries/a/-/article/8784550/image/55/out-of-control/

Special thanks to:

Bryce Green ABC 720 Perth Morning Show and Tamara Binamat ABC Perth.


Thank You ...


martin ralph - ifap - no blame culture: reality or myth?

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