Is Just Culture desirable for learning – Part 1

February 9, 2022



This is a six part series to explore the relationship between Just Culture and Learning with a diverse panel of experts. You will hear different perspectives on just culture and learning including legal, operational, academic and safety. Stay tuned for future sessions in this series.

Further information


Is Just Culture desirable for learning?


Nippin Anand, Robert J de Boer, Oessur Hilduberg, Diane-Chadwick Jones, Greg Smith, Steven Shorrock, Neil Richardson, Nektarios


Nippin Anand  00:00

Welcome to the first in a series of six sessions, where we explore the question is just culture desirable for learning. Now, before I start the session, I just want to make some few exciting announcements. First one, we now have a fresh look for our website. And for our podcast image, or the logo, the labellers website, it has a new look and feel. And what’s most exciting is that we now have a dedicated section, which we call the knowledge space, your where you will find a lot of resources, such as articles, podcasts, videos of past sessions. We are looking to introduce stories and short videos bite sized videos that you can use in your own meetings to initiate discussions and reflections. So watch the space. But also, I’d welcome your feedback on the new website. We’d love to lovely to hear from you. Secondly, we have recently started thinking sessions every Thursday, and this month, we are looking at risk assessments. And one of the problems with risk assessments. But what can we do differently in this area. As we move we will be looking at a range of topics in these thinking sessions, to include reporting systems, audits, investigations, and other areas of risk and safety. The idea is that we will have small group of people who will attend these sessions on a weekly basis. And we invite leaders from across disciplines, and to really create some some space for for debate discussions, disagreements and good engagement. The third thing I want to say is that there is a workshop coming up with with Greg Smith, where we will be looking at aligning processes with purpose in safety management systems. And if you find yourself in a situation where the documented systems or the processes have become a nightmare for your business and operations, you may find this session meaningful. You can visit our website, Nevada stock solutions slash events and look at all the events that we are planning in the near future. So that was the announcements I wanted to make. Now back to the topic of discussion. This is the first in a series of six sessions, as I said, about just culture and why just culture is desirable for learning or is it is an open question. I hope that you enjoyed this session. Yes, it started beyond live now. Well, to start with Welcome everyone, to this. This series, the six part series called it’s a it’s a series to understand learning. And the first in the series is is just culture desirable for learning. Now, the context of this today’s session is that I actually, for all my sins, I put a post out in November, on LinkedIn, where I talked about the idea of how, in a certain organisation, people view the relationship between just culture and learning through the example of an accident. And I thought and felt that the outpour of messages that I received tells us something about how people understand or are misinformed about the notion of learning, culture, accidents, truth, justice, and just culture. So for the last couple of months, I’ve spent some time reading on justice, culture learning, etc. And I thought this would be a wonderful opportunity to, to gather people who have spent a lot of time in this area thinking about this, this idea, and hence, the invite to the panellists, and I’m so pleased that you were able to join



so, in terms of the introduction, we have Diane Chadwick, who is the former director of human performance at BP. We have Greg Smith, an international lawyer in health and safety. The author of the book



and he is the director of Wayland legal, also Oessur Hi lderberg who is the head of the Danish maritime Max investigation based in Copenhagen, Denmark. Neal Richardson, who’s the director of VEDA consulting based in the UK, Nektarios Karanikas



A professor in health, safety and environment that can Queensland University of Technology in Australia, RJ Boer, who’s the author of the book safety, leadership, and academic and manager in higher education, based in Netherlands, and Steve Shorrock, senior special safety specialist and human factors at your control, but also the chief editor of the very famous magazine. Hindsight.


Nippin Anand  05:27

So I don’t know about the the the convenient diversity, which is all around gender and ethnicity and nationality. But what I really wanted to achieve in this session was was cognitive diversity. And I think we have enough cognitive diversity, diversity in this space. We have a lawyer, we have an investigator, we have entrepreneurs, we have academic, we have researchers, and we have safety specialists, specialists, I think there’s a broad range of expertise, the only one that is missing, and I would have loved to have somebody from from the frontline, some somebody who works on the operational end, maybe next time, I will think about it. So that’s really the the, the context and I want to start with a panel just to ask everyone’s views on the question that I want to pose is, is just culture desirable for learning. And I want to start with the end, the end, would you like to offer your perspective on this?


Diane-Chadwick Jones  06:23

Thank you. Thank you, Nippin. Well, so it depends on how you define just culture. If it’s the James reasoned model with criminal law wording that Prime’s the users towards punishment, using words like violation or negligent or reckless? Well, that gets in the way of learning because it just, it just takes you straight to punishment? Or do we define it as what was developed in the aviation industry in the 1950s to 1970s, which is about encouraging open reporting, and discussion of all adverse events to improve safety, and to hold off on discipline until the workplace context was understood. And, you know, I wonder how many of the people who are attending this event or listen to this as a podcast, how many of you think you actually have a just culture, but because you think you’re listening, but instead you punish people who make mistakes? And you ask, who is accountable when things go goes wrong? And of course, this leads to the hiding of incidents, and it prevents learning. For the last 100 years safety has focused on an incident reduction. Like who who did wrong point of view, and this is limited organization’s ability to grow in maturity, since the truth behind most incidents, has no does not get revealed. And the investigation stopped when they found the presumed guilty person. And so to think well, what is the purpose of adjust culture? The core mission is about learning. And let me give you a published case study from BP because I think that will make it easier to think about is just cultural light, desirable for learning, what do we get from it? In BP, we had the reason process, but we found that it lead to blame and victimisation of the frontline. And so we redesigned it with the workers and with the investigation team. And it became a set of questions rather than a flowchart. And you could answer yes or no to have multiple of these questions. So you would see the system dynamics, you’ll see the different components of what led people to do what they did know, what was the expectation clear? Was the procedure clear? Did people have the resources? Did they intend to do the right thing, but they got confused by alarms or buy the equipment. And so this was all about learning to read design questions, help leaders understand what was really going on. And the published case study shows that over a period of 18 months, there were about 350 cases. And most of those cases where it looked like people broke the rules, that those cases were attributed to system levels, system level issues, procedures being unclear, lack of experience or resources or mistake caused by labelling and this had a huge influence on learning and BP. So rather than disciplining or sacking people, they were instead part of a learning process to address system issues. Imagine that, you know, 350 people who could have lost their jobs, and yet, the and the organisation could have carried on without knowing the terrible flaws that could lead to the same or more adverse events. And so and this Of course, led to a huge realisation within the company about the underlying issues that led to people doing what they were doing, anybody else would have done the same under the same circumstances. So I just like to conclude that, that it is important how we define just culture. And that it if we define it in the way of open, open, speak up and listening and addressing issues that it does lead to learning. Back to you.


Nippin Anand  10:32

Thank you. Lovely. The only thing I would say that please stick to your time of three minutes before I’m sorry, helpful, because otherwise, we’re taking somebody else’s time. But that’s wonderful. Thank you very much is over to break break. What do you think you’re unmuted, Greg?


Greg Smith  10:51

Take it off my time, I’ll be I’ll be reasonably brief. Again, definition of just culture is important, but probably not as important as application in practice. And I think the idea of just culture is obviously a bit of a right size in response to the idea of a no blame culture, because I think workers, workers struggle if they don’t see people being held accountable for errors. That outline worthy, I think it’s it’s a nice idea, but I, I’m not comfortable with the concept that there is never any level of blame or retribution than those qualities. And, and that’s not to say, and I think part of the problem with our approach to just culture is very much directed at the frontline worker. And I think we spend a lot of time thinking about it more holistically. And organizationally, wasn’t meant for the ability of middle managers to speak out wasn’t made for the the ability of senior executives to have honest conversations with boards. It’s, it’s more pervasive than just not blaming the frontline worker for doing something. And I’m not quite sure we’ve, we’ve captured that particularly well. But really, an atmosphere of trust and fairness. It’s got to be critical, not just to learning from safety, but for learning from anything we want us to understand in our organisation. Now, I’m not a social psychologist, I’m not a psychiatrist, I tend to do understand all the human factors side very strongly. By white, we will make one quick note and then I’ll close out on my time. One of the challenges I think we’ve just culture, however you frame it, is that it runs very hard and fast up against the the typically not just a social, but a legislative framework where we drop it. So for example, if you’re an organisation and you want to demonstrate that you’re managing or risks as far as reasonably practicable, there’s an expectation that that involves enforcement and discipline. There’s an expectation if you’re standing out in front of the magistrate that you can show this this easy examples where we have discipline then terminated employees for breaching our rules. In an employment context, the just culture inquiry, the genuine honest inquiry to understand what’s going on, compromises our ability to fight Amphibs from suppliers and complaints that workers make against the organisation. So you’re always balancing these issues. But to emphasise the value of adjust culture, from a learning perspective, I recently ran a case where a person was sent to jail for breaches of health and safety legislation, and the men manager. So the magistrate might be overt comment that none of the parties in the proceedings could explain to her why the work was done the way it was done on the day in question. And then you simply because now I was interested in understanding that for the purposes of dealing with a prosecution, and I think, really, if we’re bringing any kind of agenda to safety, we diminish our abilities to learn. And perhaps that’s what sits fundamentally at the bottom of a really just culture.


Nippin Anand  14:28

Thanks. Thank you, Greg. Wonderful. I mean, what I see is the tension between the very libertarian view, which is the ideal view, which is about freedom and fairness and justice, in that sense, and how that contradicts with the legal view, which is about enforcement, which is quite interesting, because that’s what law is really interested in. That’s a very paternal model of justice, isn’t it? So and that’s what and as you said, nobody’s interested in in fairness when things go wrong, what people are really interested in is the is the Discipline and Punish model. Thank you. Thank you, Greg. That’s very helpful. We go to oyster now, Holloway, sir, what do you think?


Oessur Hilduberg  15:05

Yes, hello? Yeah. What do I think? Well, in my understanding this question relates to how organisations respond to firsthand experiences and from employees, and in that sense called just culture is desirable for being a facilitator of organisational learning. A transparent mechanism for building trust to where employees can share inconvenient information share bad news. My stance however, is that the just concept of just culture is well intentioned and perhaps feasible on paper to aid in organisational learning, but in practice, there are some barriers, barriers which makes it difficult and not only difficult, but one could argue virtually impossible. I will show the highlight two problems. One problem is related to the hierarchy in the organisation and one problem is related to competing demands in organisations. If we look at the hierarchy, just culture as a concept is viewed differently throughout the organisational hierarchy. Powerful people in organisations are prone to experiencing and an organisational culture to be just more than people in the lower end of the hierarchy. What happens is that justice is adjusted according to whom makes the error, what is seen as just by one group, as deadly the powerful people in organisations tends to be seen as unjust by everybody else in the organisation. And therefore, instead of facilitating learning, the quite the opposite happens, just culture becomes a metric by which employees in the lower end of the hierarchy are evaluated and judged resulting in the opposite of learning, namely, quietness. The second thing is that the competing demands now organisational learning is a really complex process, which is rarely related to individual experiences or events. The single event we’re just culture is an effect, we rarely constitute a reshuffling audit of the organisational practices unless they are quick and cheap. Or the exception being the single disastrous events event which threatens the very existence of the company. And in those cases, in the individual cases, where just culture is needed, actually needed, the company will tend to lean towards mitigating the judicial and liability issues rather than owning its own shortcomings, thereby missing out on the learning opportunity. So in conclusion, just culture is likely to fail as a unifying concept to facilitate learning because of fundamentally different views in the hierarchy of what is just and also because of the competing demands. Because learning is subjected to to other competing demands into organisations, especially in terms of judicial and liability issues. Thank you.


Nippin Anand  18:31

Yes, that’s the last part of what you said is, is very much in tune with what Greg also mentioned, but I think I, I think I also what I’m hearing is that how difficult it is in an organisational context or to expect an organisation to deliver justice, when the organisation is designed to deliver goods and services faster, better and cheaper. So the two are not really compatible, and we’re not just compatible, it actually sets outside of what the organisation really does. That’s, that’s, that’s great. Thank you. So that’s very helpful. Um, we go to Neil. Neil, what’s your view?


Neil Richardson  19:06

Yeah. Hi, Nippin. Hi, everyone. Yeah, it’s really interesting comments already coming out? I think. For me, I think the youngster sits somewhere in what are we actually trying to learn and and what we’re learning from, you often see just culture spoken of in a, in a legal sense, or after the event, but, but I’d argue if you’re talking about it, then the whole point, just culture has been missed. The whole point is to learn prior to the event. It’s the systemic issues, it’s the behaviours, it’s the attitude, it’s the dynamics of the organisation, that that are creating unsafe outcomes that that we’re trying to get into. So if we’re not prepared to learn up front, it’s too late. It’s too late when it’s gone wrong. There’s so much more at stake. There’s legal issues, there’s emotion, there’s potential, next of kin issues, and all of that is just not really going to allow any kind of justice Culture principle to gain traction. So, so for me, it’s about the upfront learning, you know, looking for things such as practical drift, and why it’s happening. And getting into that before we get to the point where some kind of catastrophic failure is more likely. But also, I think one of the things that we see on this point there is that just culture tends to be trained to people. You can’t train adjust culture, it’s a belief system. And that kind of goes back to the point of hierarchy, if the entire organisation and I mean, the entire organisation cannot align to a belief of what just culture looks like in their context, it’s not going to work. You can’t have a flowchart on the wall, that that people follow when it’s gone wrong. That’s just never going to work. You can’t leave it down to a city manager to change culture, that’s not going to work. It’s got to be an inbred belief. And that alone will take years to cultivate, to nurture and mature. If we don’t start somewhere with being just you can’t learn how to be better at being justice. That makes sense. You’ve got to practice it and and dare I say, follow your own shoelaces a little bit to be better at being just, it’s a journey. It’s a programme, that but so often, we see one day in a training room, flash up a flowchart. Great, we’re going to just culture and the policy just sits on the wall, and it doesn’t come alive. It just doesn’t do anything. So for me, I think some fundamental questions here in terms of what’s the purpose of adjust culture? Yes, it’s to enable the learning from from prior issues and systemic issues, but also to enable free flow of information through the organisation top to bottom. Yeah, we’ve got to allow effective audits, effective investigations, effective collaboration and conversations, all of that is enabled by this thing that we call adjust culture. For me, it’s about trust, fairness, and transparency. And, and that doesn’t come free. That’s that’s a leadership challenge. And that’s about creating a new belief system. And you got to undo your previous beliefs to get there. You don’t, Masson? Sure.


Nippin Anand  22:10

Thank you. Well, I have a number of things. One is a concept of just culture that can be evoked before something happens. That’s an interesting concept, because I I’m not sure how to get around that. Because of the time just an unjust. Also, you talk about the unified concept, your belief system, you speak about words like that, which is basically going down to the issue of culture, how do we understand culture? And it’s a very problematic area also. But thank you, Neil. That’s very helpful. We go to Nektarios No, hello, materials.


Nektarios  22:44

Hello, hello, everyone. Once more. Very listen discussion in the actually the questions you posted, about the sculpture and learning three, it made to look for research on that topic. I was quite sure I have come across anything relevant. And indeed, apart from some opinions, in some discussion papers, from an academic perspective, there is no research connecting, just capture in learning. However, what we have in academic literature is about just cultural end reporting. And this reporting is what we believe and continue to learn. So I also my patient opinion, that it’s a bit of a leap, to connect just culture directly with Lyn, because even if we encourage people to, to speak openly, transparently, to be the self authentic, and to share with everyone honestly, what happened and why it happened and how it happened, without the fear of getting funds for, for mistakes, is that information, we collect information, we say, between us, which is very important. Now, whether this will translate into learning. It’s another process because learning is something deep, it’s about changing the system, including ourselves, not imposing changes to others. So I, I agree this value infrastructure, I don’t think that there’s anyone that would say, I don’t like this culture, what it means to each of us is different. I fully agree with the previous speakers, the panellists here, and there have because we discuss about the formal title, just capture what the management does and whether we have procedures or policies and not in my experience in the industry, so that there’s another just come to issue that we might neglect. And this is the just culture at the same level, the operational level. So it’s not only about how manages act when somebody committed a mistake, regardless of outcome, it’s called the other is the colleague see that people make mistakes, how they look down on people sometimes how they think they’re full. And this is an area that we haven’t received, we haven’t started, we haven’t discussed about it for for some time, maybe not even at all. And this can impede people even if you have policies around for for metastasis, just cultural, to open up to share. And it’s easier to serve with my colleagues, if I feel an environment that lets a judge in terms of punishment, not the former punishment, but the way people behave towards me to share with them what happened yesterday, it doesn’t have to be a formal investigation. What happened to me how I managed the situation, what they could have done differently, they think we’re missing a big opportunity for legging within things. That’s for me.


Nippin Anand  26:09

Thank you. What I hear is the difficulty of translating the information that we collect in the name of safety and reporting, and really turn it into kind of some kind of meaningful change. That is a struggle. And what I’m also hearing and something I hear from you often when we speak is the the power of introspection and reflection, which is are we really reflecting enough to understand how we learn from our mistakes. And that is something interesting. Thank you. Aquarius, that’s very helpful. We go to RJ RJ, what’s your view,


Robert J de Boer  26:45

I have two propositions for you Nippin, and for the audience. And the first of those is ditional. Just Culture is aimed at differentiating between acceptable and unacceptable behaviour, and therefore impedes learning. And let’s be a little bit clearer about this just culture is traditional just culture, which is still the predominant type of approach for assessing assessing behaviour in 99% of organisations. Many of those have a flowchart to support this sort of assessment. And that is typically an even the organization’s represented in the panel today still have very much traditional just culture approach. And that impedes learning, learning. It impedes learning because it’s about because learning is about trying different things, and seeing the effects. It’s about experimentation outside what is currently considered acceptable, yet to just culture tries to differentiate between acceptable and unacceptable behaviour. And the most counterproductive elements, of course, we know is punishment or retribution. Yet traditional just culture is exactly about determining what we need to do in those terms. So my first proposition was that the traditional just culture is aimed at differentiating between acceptable and unacceptable behaviour, and therefore impedes learning. My second proposition, there is some light at the horizon, mind you. My second proposition is that restorative practice, also called restorative just culture, is actually very beneficial, is desirable for learning. restorative practice, as I prefer to call it to ensure that we don’t confuse it with the traditional form of just culture we talked about just now has been a little described in the literature. Decker, in his third edition of his just culture book describes it, I spend a chapter on it in my recent book safety leadership. And in the fall, there’ll be a new book, which we’ll come out with, which is called the sort of just culture in practice, which is written together with the forefront of this sort of practice practitioners at Mercy care in England. The store of practice is focused at restoring correlations between people who are involved some way or another in an incident. It is needed because it is aimed at restoring trust and relationships, and therefore creates a psychological safety, which is needed for learning. It includes accountability, I very much agree with, for instance, Greg’s comments that no blame culture, there’ll be little incentive for learning, we need to include forward looking account accountability. And that’s what was taught of practice is focused about it asks who was hurt? What are their needs? And what whose obligation is it to meet those needs? Now, that’s interesting. Those questions don’t don’t include any learning aspects at all. No, that’s right. But they are the necessities that we need to fill in first, before we can get round to organising a dialogue, having reflection that no tie is talked about having a sphere of sensemaking and therefore being able to learn and adopt forward looking at a country ability. I’ll be happy to share some examples in the second round.


Nippin Anand  30:04

Great, thank you, Roger. That’s very helpful. I think. So you make a distinction between the the, the attribute of just culture and respirate just culture. You say how counterproductive it is, in your words, to follow the previous one, you gave away to restorative just culture, which is about I, I find it interesting when you talked about restoring relationships, psychological safety, thinking about forward thinking, accountability, and I want to see what examples you bring it to the next round. But thank you, Steve. Oh, what do you what do you think


Steven Shorrock  30:43

it’s one of these terms that’s monolithic, concept, you know, combining two monolithic concepts. As has been said, already, it depends what you mean. Now, my basis for thinking about this is 10 years, also talking to frontline staff, especially in aviation, so controllers and engineers, and also middle managers, senior managers, up to CEO level, and also the judiciary, members of the European judiciary from many countries. And so what you see already what I see over 10 years or so, is that there’s many different conceptions already about this. And there’s just culture at the corporate level and the judicial level. And that’s two different things altogether. I’ve also been involved in oral evidence given to UK government commissioned reviews and committees related to learning from mistakes and gross negligence manslaughter in NHS health care context. And I think for me, you have to really break it down. And I think just culture is about a question of, can I be honest. And that’s something that’s that we’ve not really talked about much. In a sense, it relates to psychological safety in that way, what’s the consequences? To my being honest? And not just about an accident or incident, but just about everyday work? Can I actually talk about how we really do things, or how we did things without unfair consequences? So that’s kind of one things, I think the concept does recognise that we’re not perfect, you know, we might behave in a locally rational way. But people also do things that are grossly unacceptable, like bullying, like abuse, like hazing rituals, like cover ups, and so on. So there are there are some red lines, not only in law, but I think just in terms of our kind of shared morality. So there’s, there’s questions about that that are important. And we could turn around, in fact, to say, well, wouldn’t unjust culture be desirable for learning? And then it becomes quite absurd. So if neither an unjust culture is desirable, nor a just culture is desirable, then we’re kind of we’re kind of lost learning as well. Is we also have to think about that. And I think the concept is really about disclosure. Traditionally, regarding events and conditions. That’s what the concept relates to. But it’s also about everyday work has been, as has been mentioned earlier. And what are we actually learning about? Are we learning about events and conditions? Are we learning to be better human beings? That seems also quite important? Are we learning to be better, more ethical organisations, I guess you’re close, it’s worth looking at what these concepts have in common. And one of them is feedback, because you need feedback for justice and learning. One of them has consequences because we learn from consequences which also determine our responses in terms of justice. I think fear is relevant to both. There’s fear in learning. And there’s also fear of justice in some cases, of course, and both can only be measured subjectively. And so we can never really get a full handle on just culture or learning because we can’t really mention them. So the last thing I’d say is that it doesn’t transfer well across all organisations, industries, national cultures, or, or professions. And so you’re going to find lots of variability in how people see both of these concepts and the relation between the two.


Nippin Anand  34:20

Great shared morality ethics. Nobody talked about it so far. So that’s very interesting. When you talk about learning. That’s a very powerful actually even to start with the concept of looking at learning to be better human beings. What a powerful statement. Let’s go back again, once more, another round. And this time, we will start with the end once again and then go, do you have a choice you would be would like me to ask a question, or would you like to build upon your


Diane-Chadwick Jones  34:52

arms gonna build? Right so what I’m gonna do is I’m going to build on Steve, and I’m going to build on ERISA, and I’m going to build on a comment in the chat. Okay. So, so also made the point about the hierarchy, how the decisions are made on what is just people making mistakes and pushing the blame to the frontline that the the people who make the decisions about what are the underlying issues, those are the more senior people and they’re pushing blame. And then Steve is talking about the morality of that. And you’re all we all leaders behaving with integrity. And I’d like to bring in meevo Lachlan from maybes comment, which is, imagine the day when we judge the actions of those higher in the higher hierarchy for the pressures, constraints and gold conflicts, they introduce that drive the actions of the frontline. So here’s where the practice that I have, can can shed some light that we learned from slumber j, we learned from other companies who were, in fact, escalating the conversation on just culture up the up the hierarchy up the hierarchy. And so instead of it just being pushed down to the, to the people who were touching the valves actually say, Well, hang on, Why were those valves not maintained to the level that they should? What was the resourcing decision? Why did there only one person on this job instead of two? What, how was the scheduling word? And so we worked up the organisation. And so in BP, there was the escalation of accountability through the just culture process. And that makes a huge difference in terms of under understanding those organisational issues, and addressing those organisational issues. So just wanted to go over dress that those points because it does come to morality, Steve, and I, because people think they’re very good. But, you know, we all think we’re nice people. But it’s when these kinds of conflicts are discussed more openly that we understand what the really the impact of what we’re doing. So back to you, Nippin.


Nippin Anand  37:12

Yes, I hear the word escalation of accountability upwards. Interesting, then. Thank you. Greg, what are your thoughts?


Greg Smith  37:23

Thanks, nuvens. It’s an interesting conversation, I’ve got more of an observation then to flesh out anything just based on what I’ve been hearing. But I’m just really curious to throw out there this idea that because we talk about conversation, we talk about trust. We talk about, you know, burn better people and learn to be better organisations. And I’m just curious about the extent to which safety, safety, there’s two things the extent to which safety is sort of predisposition towards procedure, realising everything undermines our ability to achieve any of those outcomes. So even the idea of a just culture, this idea that we treat people justly and fairly, gets put into this process flowchart and it sort of, I think, as soon as, as soon as you you’ve got that procedural, procedural isolation of human intellect and human empathy, you, you’re kind of absolved from responsibility about really thinking about the property, you just have to move it through the different gatekeepers and get it out the other side. And I’m also curious about the idea that we drop, we drop, what are really whole of organisational traits into a box called safety. And we sort of close it off. So instead of us a just culture, we stick it down and say, right, that’s what you do. When something happens in safety. You apply this model as opposed to say, organizationally, institutionally, what do you want? Now you you wouldn’t do it to your own family? Wouldn’t you wouldn’t box up different elements and say, well, just culture when it comes to that, and then it’s a free for all over here. And it seems to me that can save you were very good. I think safeties align, I think human resources does it as well. But at taking what are ostensibly simple, reasonably straightforward concepts and good ideas like safety culture, like safety, conversate, culture conversations, and others and sticking our safety label on them, and procedure realising them and effectively sucking the life out of those and turning them into a bureaucratic set of gates that we have to pass through. I’m not sure that answers any questions, but I think it’s a different way of thinking about some of those concepts we struggle with


Nippin Anand  40:01

Absolutely, that’s makes a lot of sense. You’re talking about morality and justice. When you look at the term, just culture tree and flowchart or model, it’s almost kind of an oxymoron. They the two, the two don’t come together very well,


Greg Smith  40:16

that is so consistent with what modern justice he is modern justice is not necessarily about a fair result anymore, I think is largely a product of what’s called procedural fairness, so long as you go through the processes, and then the outcome is is just by not necessarily sure represents a live person’s interpretation of what’s right or proper.


Nippin Anand  40:46

Yeah, and we see that a lot in the marine world, the utilitarian view on justice and just culture. Thank you, Greg, this is very helpful. We go to ICER. Now is we have any thoughts from the discussion so


Oessur Hilduberg  40:58

far? Yeah, absolutely. I am from the maritime domain and we cannot and I won’t attempt to generalise across other domains. I will make two points. One is I would point out the the premise of how openness, disclosure clarity sharing information as an organisational property is good, yes, but we should not underestimate and in particular, in the maritime industry, how organisational secrecy is embedded in how shipping companies fundamentally work. Namely that this organisational secrecy is really the driver that hides the difference between work as prescribed and how work is actually done. That there is this embedded need for organisational secrecy to manage prescribe work versus work has gone openness is not desirable, really, especially not to the outside world, which really hinders this disclosure thing. The second thing is, if we in an environment like that, try to implement adjust culture, which is a very hot topic and everybody should have one and by legislation, sooner or later in the maritime industry, we should also have some such a concept. The problem is as known by most people is the very concept of having an organisational structure like culture, which is poorly defined. And if we have a concept like that, which is poorly defined, able as an unstable definition, it lends itself to behaviourism meaning that we talk about attitude and commitment and belief which are religious, a religious conceptualization of safety, a ritual, a religious conceptual conceptualization of how the organisation is supposed to work, and those commitments and beliefs. Will America pessimistic about how they will be shared throughout the organisation because we have very little in common in organisation when we talk about the hierarchy. So even though we can buy campaigns and posters and seminars try to instil a certain religious belief within the organisation, I’m afraid that will be inherently difficult.


Nippin Anand  43:43

Yes, supported by a huge vocabulary that we have around safety and compliance. But also but reminds me of an example about operational excellence when I start to to interview people in the organisation. What do you really mean by that? Nobody really has a clear idea, except that the last person in the chain should work harder to achieve the best results. I think that’s that’s powerful voice. Thank you. It’s all behaviourism isn’t it? Neal, what are your thoughts?


Neil Richardson  44:16

Yeah, I’ve just scribbling notes here as people are speaking and there’s probably too much to go through really, so I’ve got to pick something really and just go go with that. But um, it’s interesting that that point of disclosure has just been made. And I just wrote here, you know, is this potentially a case of Turkeys voting for Christmas because at the end of the day, if we disclose the reality of our operations there’s a heck of a lot of work I would argue to them be done to rectify resolve and bring that back to some kind of desirable state whatever that is. That no one likes the the lid lifted on the reality of their operation as much as it closes the door and pretend it’s not there. I’ve worked in the past with clients that are very enthusiastic and willing to have a just culture. But when you start revealing, like reality of operations, it’s like, can we go back, please. And if he can’t shut the door, so maybe there’s something there, you know, where, where we haven’t, again, got that belief as to what we’re trying to achieve given a purpose with the whole, the whole intent of improving efficiency, Operation Safety, whatever it was, we’re trying to do with it. I think sometimes, as has been said, here, you know, it becomes a process becomes something that that the regulator says we have to do. And there’s absolutely zero purpose to it. And for me, it has to go back to purpose. If we don’t know why we’re doing this, we probably can’t define what it looks like in context, because there’s another word we need to discuss. And therefore, our efforts surely are just going to not move beyond a procedure or a poster on the wall. And I’m just wondering if industries have actually got the appetite to create just cultures or whatever, we want to label this thing. psychological safety? Have I actually got the appetite, either in terms of effort? Or even is it going to reveal something that that makes them feel very uncomfortable? And I think maybe there’s something there? Maybe some interesting, they already do it? And they’re better than that? I don’t know. I don’t know. I don’t think we poke that enough. In my experience, and I’m being honest here that most just coaches don’t get off the policy.


Nippin Anand  46:29

Takes me it’s much appreciated. We go to, to Nick clarius. No, because any dependents any thoughts? Yes, sure.


Nektarios  46:44

I think the message in the Message coming across the discussion today is just culture is very context specific. So we cannot have the normative just culture to transfer directly. Concepts and policies and procedures, but data procedural justice, as Greg said, from one subject to another, I think we can all agree that, so it is more a lot to think and a local phenomenon. I would like just to do to make a comment on what Roby Yun said about the restorative culture that yes, we have a few only tattoo some books regarding the safety arena. But as a concept, restorative justice has been quite old, and has been tested with, you know, results that are not always successful in other settings. The the last thought I would like to, to, to share with us that the dust Auden’s US culture, I think that does not it is tested after adverse event, any incident or accident mistakes, but there’s something incubated alien system. So we, when we don’t give the capacity, the resources, the space, the time with the operator needs to, to control the resources to operate the system, with safety, in addition to any other objectives. And when we have the illusion that a trained certified professional can deal with everything. Actually, it’s injustice rooted in the system. Because the expectations we raise towards the operators. Then, like you agreed, you will trade you attended the education you signed off to complete it something is no problem now. It’s something rooted into the system. So we need to bait interests. And we just test our just casual and introspectively after Buffett started thinking,


Nippin Anand  49:01

interesting and very, very different from Neil’s idea, which is to try and do something about this concept before something happens. That’s an interesting dynamic materials. Thank you. We go to RJ what you wanted to share an example Are you right?


Robert J de Boer  49:21

Correct. Yep. Imagine that you see a gold worker crossing a freeway amidst uncoming traffic? How would you approach that in a just culture setting? Well, you would call him in and start talking about what sort of punishment would be justified under those circumstances. It is a sort of practice approach. We would use much more what Greg was saying the empathy to human interaction and trying to understand why it made sense for him at the time and this is a real life example mind you. We will also in that discussion, make clear that from a road board fective the crossing of a freeway is really damaging, it is not the way that we believe that work needs to be done. Nor is it the way that we believe that our road workers be its subcontractors or own people be perceived by the public, or the way that we will want to be read about in the papers, of course, knots. And in that discussion, we will be able to allow the vote work to tell his account. And he would actually say that he went to his boss to ask for permission to do this, despite the oncoming traffic, because otherwise do good works would be delayed by another four hours. And he would say that he was actually waiting for a crash absorber car to come and help him do this. But that whoever’s in the load boards own internal workings, this hadn’t been planned correctly. And that that was why this delay had occurred. It is crossing of the freeway was intentional. In that sense, in differentiating between acceptable unacceptable behaviour and adjust cultural approach, we could be very clear about it. But it was also with the very best intentions. And with the goal conflicts, which are inherent in everyday work just about all the time, we as a road board would make clear that this would not this could not happen again, that this was a once but never again type of action. And that would impose the forward looking accountability on not just a load work itself, but also his boss, and the rest of the subcontractors. And we will be able to address the errors in planning. And we would now have the disclosure to pass on these learnings to other subcontractors for the road board and to our internal organisation. And so this this example shows you how by first rebuilding trusted relationships and allowing people to tell their accounts and not being focused on is it acceptable or unacceptable behaviour? And what should the consequences be that we are able in an in a somewhat indirect manner to create many more layer learnings for the organisation than we would be able to in the traditional approach? And so, as you might imagine, I’m all for sort of practice. And I’m looking forward to helping more organisations to implement it.


Nippin Anand  52:12

Yes. Thank you, Roger. What I hear is a very Kantian perspective on just Kota from what you just said, is the intent that matters most than the consequence of it. I would ponder upon it a little bit more. But thank you. That’s very, very well received. Steve, what’s what’s your view?


Steven Shorrock  52:33

I just like to go back briefly to the issue of fear and honesty, I think just culture is one of these concepts that can be over bureaucratized and over intellectualised. And what’s interesting to me is to imagine a conversation or a setting where you sit down together, mixed professions, mixed hierarchies, and so on, maybe start with the question, are you prepared? For me to be honest about how I have to work on an everyday basis? Forget about incidents? Because incidents just emerge from everyday practice? So it’s not, I mean, it’s relevant, but it goes back beyond that. And if you are, then how can we have the conversation and remove fear from that conversation to talk about everyday work and the kinds of things that we have to do? That that’s something that I think is more interesting to me than certainly any kind of flowchart or any kind of committee, and that applies to those at the top. I mean, everybody’s making trade offs, shortcuts work arounds all the time, whether they’re a CEO, whether they’re a judge, a prosecutor, frontline operator, safety specialist, or anybody else doesn’t matter. The other thing is that about the humanising this is we tend not to think about this from the perspective of those who are harmed but are not workers. So in a healthcare context, for instance, that’s the families of people who have died or been severely injured in medical accidents, for instance, or incidents. I think by the over bureaucratization, and legalistic approach, what can be missing from their point of view, and I’m in touch with several families, for instance, is a simple apology. Now, this is quite bizarre, because if I were to bump into any of you on the street, or certainly drive into your car, the first thing that I would do is apologise if I thought that you know that my carelessness or my inattention or whatever had something to do with them. That’s just natural human behaviour. Now, when somebody gets sick when somebody dies in hospital, or when somebody is abused in a care setting, for instance, by staff, which happens quite a lot, the apology that either is not there, or it’s some kind of non apology so that needed for justice and also amends is needed that we have to make amends. And again, that has to be genuine. And going back to RJ his comment about restorative practice. These are very old concepts that go back beyond beyond ideas of safety and just culture and justice is a very old concept that goes back at least as long as safety. You know, since we had to escape Sabre toothed tigers and everything else. So, yeah, I guess just to summarise is to try to humanise this idea and don’t get too caught up certainly not in flowcharts and not in bureaucratize it too much because the more that you do that, the more that you create silos and the less human the whole thing becomes, just sit down and talk about how you actually have to work. When when you do something that harms somebody say sorry and try to make amends for it. It can be over complicated, I think.


Nippin Anand  55:57

Yes, very interesting. A lot of thoughts come to mind but I just wanted to share one small story with you where ship capsizes and the captain is in a complete trauma. And all that is offered in the name of of support is to paracetamol was to get get on with it. That’s that’s that’s the reality of, of the shipping industry. At least I don’t know how the idea of, of humanising I think this is the core of everything which is humanising it is going to gel with this, and but I but I can’t agree with you more at least at the level of the the the tension between procedure realising it, and I think some of you have a lot of you have talked about it and, and actually offerings, this this genuine support and humanised view of just culture. Great. I think we, we are well within time, which is great. There, we have six more minutes. And if there is any panel question, this would be a good time to take that before we take leave. I will just have a look. It’s mostly comments this. Okay.


Diane-Chadwick Jones  57:28

I mean, I wonder what when people listen to this, I think well, how do we do this? And I wonder whether a short cup of two or three points on that. I mean, sometimes it’s emergent, like the Camp Bastion case study. Sometimes it’s about a management stand, where we have so many repeat incidents, and so much blame. We know that we’re behaving as if we’re the victims of the bad things that the frontline are doing. But actually, we are the ones who decide the resources, we’re going to take a stand on this, we are going to behave in a more moral way. And look, look at the whole the all the influences or the third way, which is putting in a process and that educating the organisation as the BP case study. So in the middle one is the Siemens case study where there’s the the management stand. So I wonder whether that’s a helpful comment to the many people who are who are listening to this, was it? How do we do it? And I think there’s there’s not just one way? I think it depends on the organisation. And and so that’s my offer.


Nippin Anand  58:37

Yeah, absolutely. I think it’s a good point. The the idea really is to ponder over the differences and some serious questions, but then I think it’s, it’s, in my mind, at least, it’s not an idea to offer solutions. It did the to to help people understand how complicated a topic this is. And it’s so so depends upon the organisational context, national context. And and many other variables, I think it’s we have given people enough food for thought to think about these things, which was precisely the idea for this conversation. But I just want to remind everyone who’s listening to this, that we will be turning it into a podcast and a video, which will very soon show up on the LinkedIn page. So you were more than welcome to, to look at it in your own time, and share it with others. But I, I feel we have achieved so much. Just just open up the discussion in this first one hour, and then see how it goes as we as we move forward. I mean, I would love to interact with just all of you and do another round of this and see where this goes from here. But very, very grateful to all of you for taking the time to for this serious discussion. Often we are told on LinkedIn that it’s all about echo chambers and people just agreeing with each other. I think that wasn’t the case today. We all had a different perspective on it. That was quite good. I’m very happy with it. So thank you once again for joining. It’s it’s it’s a pleasure Good to see you all. And thank you everyone who’s listening. Thank you for your time is. Thanks, everyone. Thank you. Thanks great, I’m going to end the broadcast so what did you think? I hope you enjoyed the podcast then just listening to these different perspectives on just culture and learning. One thing we heard was that how thinking about just culture differently as a process can bring change in an organisation. And that is an interesting perspective. Because that would mean that we really need a standard process that can deliver but just culture. We heard an alternative perspective, which is justice and just culture means different things to different people in an organisation, and to someone in a position of power. Just Culture could well be a tool for control and authority. And often this leads to manipulation of truth and facts. So can truth and facts ever be uncovered using a process? Can it can that process ever challenge the status quo, and the authority in the organisation? Something to think about? Secondly, from the same person, we hear that an organisation is not really about seeking justice when an accident happens. Because justice and just culture is never a priority. And for that matter, even learning is never a priority. When there is a major accident, there is far too many other risks at stake. And so there is a lot of talk these days about moving away from big accidents to promoting learning, and the idea of just culture, from everyday work from everyday happenings. What kind of learning would that be? Who would be interested in that learning? Is there really a business case for this kind of learning? So we hear that, from a legal perspective, it’s not really about just culture and justice, seeking to understand the difference between process and reality, or, as some would say, work has done in work as imagined. And then trying to understand whether it’s an innocent mistake, or a matter of negligence. What the law is concerned about is that what you document in your processes, is that being followed is that being understood on the ground. And that is a very different understanding of just culture and justice. We also hear the idea of invoking just culture before things go wrong. So why do we have to wait for something to go wrong? Why not evoke just culture, when things are going well. And that is also a different perspective on just culture. From another perspective, we hear that the relationship between just culture and learning is a huge leap. Because you can have adjust culture. And then you can have a very open reporting system in a very honest reporting system. But then the information that you collect as a result of that culture will still need some kind of translation into learning, which requires effort, which requires thinking. So there is a big leap. When you want to go from just culture to learning. It’s not really about collecting information. It’s much more than that. That was interesting. We then hear about the concept of restorative just culture, which is not so much about blaming and punishing people, or the binary divide between innocent mistakes and and gross negligence, but it is about forming relationships forming trust. And both accountability and psychological safety are considered important from this perspective. Finally, we hear about the need for being honest with mistakes if we really want a just culture. We want people to be honest and Tell us what mistakes they have made, no matter how serious those mistakes are. But then, the question is that, can we ever be honest about every mistake that we make at work, or people make it work? Think about bullying, harassment, sabotage, harm, crime? Can we really be honest about these things? So, and then there was a question asked by the panellists that we really need to think about learning what early learning means. Is it about his learning concerned with being better people being more ethical organisations? Or is it about learning from events and purely about events? And I think one of the issues of this panel discussion, as I observed, it was that there was very little discussion about learning, and a lot of discussion about justice and just culture, something we will explore in this series as we go, why is that so? There was also very little focus on ethics, politics, morality, as a ground for justice, we did not even raise issues about just culture, as a discourse, a discourse of punishment. From the perspective of Michel Foucault, justice as a social contract, we did not talk much about just culture as a discourse of propaganda, which is absolutely opposed to learning. We did not touch about upon the matrix and the mantras of zero harm, and how this impacts upon justice at every level in the organisation. Finally, one, one feedback I received was, I thought, very reflective, and this comes from the head teacher of a school, he says that your panel talks a lot about justice, which was fair enough for a debate about just culture, and less about learning and its nature. And I think that was that was very well captured. A learning activity, he says is different to carrying out just an activity or performing an activity at work, we perform tasks that we should have already learned to do. So organisations would like their workers to perform their tasks reflectively. But this is an additional skill. And it is worth considering what is its relationship to learning. Mistakes are very much part of the process of learning, they should be a built in expectation of any good learning environment, for example, in a school, if you want students to take risks, because unless they do things slightly beyond their competence, they will never increase their competence. So it’s not entirely clear. That is the process when we talk of a learning culture, in safety critical industries, the same as in how we expect it in the schools. Well, they can be mistakes, or they can be learning from mistakes. But mistakes are still very much to be avoided. And I think that’s interesting from the perspective of the culture that we have in many safety critical industries. So can we simply take a culture of learning which is all about reflection and deliberation from a place like a university or a school and bolted on to a safety critical organisation? I think that’s a very interesting thing, or very interesting way of looking at it, that learning, thinking, reflecting, allowing people to make mistakes, is not a culture of safety critical industries. So there’s a lot to think about in this six part series. And so there is a lot more to come. Stay tuned. I am so looking forward to the next few sessions. Now for the best part. If you really enjoyed listening to this podcast and want to think, reflect and dance with different perspectives, yes, dance with different perspectives. Follow me on LinkedIn, on my company page, Nevada solutions for email me at Nippin Anand at Nevada solutions, and I will add you to our mailing list. There is a great lineup of events planned in the next few months, so I wouldn’t want you to miss them at all. As usual to all you curious people. Thank you for wanting to know more than what you knew yesterday. It’s both very rare and refreshing to find True learners in this world. I wish you a pleasant day and night. Goodbye