Tag Archives: reporting

Just culture: Who are we really afraid of?

When we think about just culture, we usually think about accidents and incidents, associated ‘honest mistakes’ and ‘negligence’ (by whatever name), as well as official responses to these, at company and judicial level. The notion of just culture is driven partly by fear; fear of being judged and blamed, especially fear of being blamed unfairly. The fear is felt most strongly by operational staff, who are at the sharp end of organisations and have sometimes faced disciplinary … Continue Reading ››

Don’t shoot the messenger

file0001939915281“The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.” Annex 13 of the Chicago Convention (ICAO, 2001) “… the report shall protect the anonymity of any individual involved in the accident or serious incident” (European Parliament and the Council, 2010). The report that is mentioned here is the final report of an investigating authority in … Continue Reading ››

Don’t walk the talk

KONICA MINOLTA DIGITAL CAMERASafety does not exist. At least not in itself. There are no ‘from above’ given signs that inform us what safety is, how it works, where the boundaries are or will be, or how safety should optimally be understood. Whatever ‘safety’ is, it must be a human construction - a social convention on how to see and talk about certain aspects of reality. This is not to deny the often tragic reality of ‘accidents’, … Continue Reading ››

Safety without borders

file000926134998Communication has become a catch cry for both the safety profession and regulators, yet it seems that significant barriers exist from multiple stakeholders to prevent or discourage real communication. Professor Sidney Dekker challenged us with his writings on “Just Culture”, to build organisational practices that encourage and foster open communication both for success and failure, that foster broad and honest information exchanges. The computer industry has been a leader in building active participation in information sharing, most prominently … Continue Reading ››