These different sort of cultures will impact on how incidents and accidents are dealt with in an organization:
Organisations with this sort of culture take an individualistic approach to human error. This means that when an incident occurs we want to find out who it to blame and then retrain them, discipline them or sack them.
Because there is a focus on blaming people this culture is associated with a fear of sharing errors because people don’t want to be blamed. Because people are less likely to share errors some believe that this sort of culture isn’t healthy for long-term improvement of safety in the long term.
The reason why blame cultures are so prolific is that blaming someone seems to satisfy us that justice is being done, and also it is the easy thing to do – retraining or sacking someone is much easier compared to reviewing and changing computer systems and organisational procedures.
A learning culture is almost at the opposite end of the blame culture. Here people aren’t blamed and error reporting is encouraged to maximize the learning potential from every incident and near miss.
The aviation sector is often held up as a model for other safety-critical sectors to follow, and within this pilots can apparently report error and avoid any repercussions just as long as they report it themselves. Some see this as an ideal, and in the face of falling victim to some unfortunate sequence of events that could have been prevented by some identifiable individual or individual it might seem too much just to let them off (something that harks back to the blame culture).
To see how one might give a strong positive response to an incident, rather than let destructive negative thoughts take over, it is worth watching this film by Martin Bromiley:
If the two cultures seems like extremes above then a just culture seeks to rebalance the system. The key here is accountability. Where individuals have been negligent they should be punished, but where they have been part of an unfortunate sequence of events they should be free from reprisal.
Staff must trust in whoever has the power to decide when someone is at fault and when they aren’t. This is essential to maintain the open spirit of error reporting and learning, which is not easy to accomplish. Sidney Dekker explains further:
If you found this interesting, maybe you’d like to take a look at some of the other stories and articles in our Learning Zone?