Surface Ripples

"Just Culture"

How many of us have been guilty of “finger pointing”, “blame gaming” or “witch hunting”?  I certainly have.  The human mind naturally  looks for reasons that something happened – the simpler, the better.  It’s easy to understand when just one part failed, one person didn’t do their job correctly, or when bad weather rained the match off.  One cause = one effect = case closed.

In some cases, this does happen.  In many, things are more complicated.

I work a lot with the aviation industry.  When a plane has an accident, it’s big news.  Thousands of people die every year from car accidents or gunshot wounds than from aircraft accidents, but we rarely hear about these. Aircraft accidents are rarer, and usually happen at high altitude to lots of people all at once.  The skies are not a natural human element.  Yet aviation is one of the safest industries in the world because people:

Share knowledge and experience of what went wrong

Work to fix it

Check that whatever’s been proposed as the “fix” is being implemented

Contrast this with others (I won’t name them) where certain senior figures are seen as all-knowing and therefore incapable of making mistakes; yet they do, often with fatal consequences.

In aviation, accidents are usually the result of several problems all occurring together or in sequence to cause something to happen.   “Pilot error” or “human error” are often the first suggested causes of an accident.  At times, this is the case.  Looking at the problems experienced by the Boeing 737 Max, a number of factors combined to cause the problem.  Cold comfort to those who lost loved ones in the accidents that followed…

“Just culture” is the name given to a culture which looks to establish the causes behind an incident without necessarily assigning blame to any one individual unless it is clear that that individual was indeed the sole cause.

Take the following:

• It’s late at night at the airport
• People in charge of servicing aircraft are tired
• An “urgent” repair comes in
• There is pressure to get it ready - fast
• A small part is needed; a mechanic goes to the stores
• The stores are poorly lit; the supervisor is out on their break
• Several other parts look identical with only 1-2 millimetres difference in dimensions
• A stores clerk earlier didn’t place the parts in the correct location
• The serial numbers aren’t marked on the parts due to their size
• Poor lighting prevents the mechanic checking them properly
• The mechanic grabs what he/she thinks is the right part and returns to the aircraft, fits it and reports to their supervisor that the job is done
• In their rush to get the aircraft out, the supervisor doesn’t check the work properly
• The aircraft is released for service, takes off and the part shakes loose
• The aircraft crash lands and a near-fatal accident is just avoided

Who is at fault?

As we can see, a combination of circumstances has occurred.  “Just culture” would see this and conclude as such.  Processes would be reviewed to ensure that the events above could not recur and personnel involved might need extra training.  No one was solely to blame.

The problem for many is that this can be a complex and time-consuming process and doesn’t result in one clear “problem area”, but rather many.  Easier to point a finger at the first easy target and blame them.

As life becomes more complex and interconnected, we as leaders need to bear this in mind and understand the complex interplay of relationships, departments and teams.

I’ve spent more than half my life delivering change in different world markets from the most developed to “emerging” economies. With a wealth of international experience in international financial services around the world running different operations and lending businesses, I started my own Consultancy to provide solutions for improving performance, productivity and risk management.  I work with individuals, small businesses, charities, quoted companies and academic institutions across the world. An international speaker, trainer, author and fund-raiser, I can be contacted by email. My website provides a full picture of my portfolio of services.  For strategic questions that you should be asking yourself, follow me at @wkm610.

Labels: Crisis Management, Customer Care, Leadership, Productivity, Teamwork

posted by William Martin @ 12:58