Is just culture the answer to preventing accidents?

Some years ago, I came across a ship incident where a bosun (the head of the crew) was put through the Just Culture Process. The claim raised against the bosun was that he had deliberately thrown a hammer on a wall within his workshop.

This man did not intend to attack or harm anyone, he was merely venting his frustration. But instead of checking with him why he felt so frustrated, the company safety department decided to discipline him.

This little story highlights some fundamental problems with Just Culture both as a 𝗰𝗼𝗻𝗰𝗲𝗽𝘁 and as an 𝗮𝗽𝗽𝗹𝗶𝗰𝗮𝘁𝗶𝗼𝗻 𝘁𝗼𝗼𝗹 for accident prevention:

• When things go wrong, our first reaction is not to listen to the story of people involved but to ask – ‘what the rule book says’?

• We look for a rule or a process not so much to understand what went wrong but to seize control of the situation.

• Who gets to choose the rule, which rule applies best in the situation? Accusation and blame, not listening and understanding, becomes the driving force of the enquiry.

• Human motivation and emotions (in this case frustration) are deeply personal and subjective; how much does the process help?

• And so, we get busy focusing on petty details. Time and place of incident, extent of damage to the wall, potential risk of someone getting hurt (even when no one was present), bosun’s hours of work and rest etc. all under the pretext of collecting ‘factual evidences’.

𝗣𝗼𝘀𝘀𝗶𝗯𝗹𝗲 𝗼𝘂𝘁𝗰𝗼𝗺𝗲𝘀:

👉 Fire the bosun

👉 Reprimand the bosun

👉Seek an apology from the bosun

👉 Bosun to attend training on anger management

👉All shipboard hammers to be secured with chains and locks

👉 Future use of hammers on the ship subject to office approval


Where a simple solution would be to listen to the bosun and understand the source of his frustration, the typical reaction is that ‘we don’t have time for that’; or ‘this is not a repeatable process’ or ‘a scalable solution’.

What could be more traumatic and demeaning than putting a frustrated person through a disciplinary process?

Just Culture is a disciplinary tool with its 𝘱𝘳𝘪𝘮𝘦 focus on accountability not learning.

I often ask myself:

Why accountability appeals so much more to us than learning?

Do we really achieve much from a Just Culture process?

And most importantly, can culture ever be turned into a process?

𝗜 𝗵𝗮𝘃𝗲 𝗻𝗼 𝗶𝗻𝘁𝗲𝗿𝗲𝘀𝘁 𝗶𝗻 𝗮𝗿𝗴𝘂𝗶𝗻𝗴 𝗼𝗿 𝗽𝗿𝗼𝘃𝗶𝗻𝗴 𝗺𝘆𝘀𝗲𝗹𝗳, 𝗜 𝗮𝗺 𝗴𝗲𝗻𝘂𝗶𝗻𝗲𝗹𝘆 𝗶𝗻𝘁𝗲𝗿𝗲𝘀𝘁𝗲𝗱 𝘁𝗼 𝗵𝗲𝗮𝗿 𝘆𝗼𝘂𝗿 𝘁𝗵𝗼𝘂𝗴𝗵𝘁𝘀.

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