This is the second part of 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.
Nippin Anand 00:00
Hello and welcome to the second session in the six part series is just culture desirable for learning with me Nippin Ireland on your podcast embracing differences. I know it’s been a while since I published my last podcast. It’s been a slightly hectic time when I’m very delighted to present this session where I’m joined by Oessur Hilduberg from the Danish maritime Accident Investigation Board, Diane Chadwick Jones, human performance expert, Neil Richardson from VEDA consulting and Nektarios Karanikas from Queensland, Queensland University of Technology in Australia. So it’s the same set of people who we met in the first session. But on this occasion, we will take the discussion a little bit more deeper. I’m obviously very interested to hear everyone’s perspective on just culture and learning. But one of the key questions I really want to explore in this podcast and we’ll see how we go is get a process or a flowchart or a model on a tree, as we call it, really deliver justice in the organisational context. So I hope you enjoy the session. So we are live now. Good morning, good afternoon, good evening, wherever you are in the world. Thanks, once again for joining us, in the second episode of this series, is just culture desirable for learning. So we, we did the first session with eight of us this time, we have own instead of eight and nine, we have Dan with us we have new, we have ocean, who we can’t see at the moment, but I’m sure he’ll come back in a minute. And we have victorious. So we had some great feedback. The first time very constructive, one of the things we didn’t do very well was we went too much into the breath. And we we didn’t have time to unpack some of the things so one of my one of the purposes of this session is to go a little bit more deeper this time rather than going to to lose that the second thing which is important is to really unpack the meaning of of just culture and learning. I think there’s there’s three words there justice, culture and learning and it’s it’s very abstract in some sense. So we’ll try and unpack them a little bit. So I think that would be so we’ll we’ll we’ll keep it there is no it’s not as structured at this as it was last time. It will be much more organic the way we go. And what I’d like to do the stock maybe maybe ask question what he what he thinks about it.
Oessur Hilduberg 03:04
Yeah. Putting some depth to it, it’s tempting to when putting some depth into concepts like just culture or safety culture, stuff like that, it it tends to go into an academic depth academic discussions about what Justice what culture is and that will be an endless discussion on that. As an accident investigator i i am preoccupied with what happens in organisations as we investigate organisations, how do these safety related theoretical concepts how do they perform in the wild what happens to these theoretical constructs when they appear in in organisations and how organisations translate these rather academic concepts into something tangible and to put it short what happens? We observe something really interesting, which is that we come across some organisations with well developed practices of just culture where the managers make themselves accountable for what happens for the incidents and the for learning and the frontline workers also participate very closely with the managers. what characterises these companies or organisations is that they are quite small, often family owned, and they and they have no idea of what just culture is but they perform nonetheless, on an everyday basis, and they learn a lot from it. By using this there’s a trust in the organisation of fairness, letting people be heard and so on. Now, this does not translate very well into the large organisations that will be the largest shipping companies where quite the opposite happens that they have very clear just culture concepts in play procedures, organisational structures in place, but what happens is exactly the opposite. They design an a culture of injustice, where the just culture concept and the procedures are used for, say, getting rid of people. It’s used for overly responsibility sation. And what we typically hear from these managers is the pressure of the competing demands from outside of accountability from regulators from liability issues, civil liability issues, and so on. The customers demand that somebody is being fired. So this responsibility station, so there’s this element of that. And what we have an interest in is to, to understand how how these concepts translate into in the world in form of systems, really. And I, that is what we’re curious about, how is this? Do we have success stories of this, on how just culture really can be in large organisations also be implemented?
Nippin Anand 06:31
Fascinating. I’m hearing a few things here. One is kind of process deliver justice. And particularly so if you go from a small scale, family oriented organisation to something really big, where we almost lose touch with that personal touch with people. You also talk about external motivation to I don’t know why I wrote the word. You talk about success stories. I don’t know what the success stories were one of the thing one of the stories that comes to mind and it relates to what you said was, was, was the third officer on board a tanker. And there was about 300 extinguishers to be to be signed off on a monthly basis as a part of week weekly inspection, or monthly inspection. I can’t remember now. But one of the fire extinguishers wasn’t signed off. And it happened to be an inspection on both the inspector came on board. And he found that that one inspector one extinguisher was missing. Now, just culture process or three or flowchart was applied to it. This person was considered complacent. Why, because the inspector left a nonconformity for the vessel, which goes against the marketability of the ship. And this person was was actually ultimately removed from the company. That became the trigger point for for for him leaving the company. And I’m just wondering, as you spoke, yes, there was a process in place, or just culture, that process was used. But did that process actually deliver justice? It’s an interesting thing. nectaries your thoughts?
Yes, very interesting area, I think the difference between the small and being organisations or in small organisations you have the procedural justice, how you treat people. And the other type of justice that we call distributive means, how we say the resources, who has control over what and what expectations we have, from a view, are usually concentrated in a small space in between people. So it’s easier to instil this just cultural concept. When we talk about big, large organisations. Those two areas, I think they are quite separate from each other. So now we’re talking about processes. So we have made the sculpture, the function, how to do it say, to deliver the sculpture, which is something like the procedural part. But we forget to connect that with the distributive part, to be a bit more less academic and more clear. To me, Justice of fairness has to do with the expectations that we have from somebody who uses the resources under control, but relative to the opportunity given. And when I’m talking about opportunity, I’m talking about individual capabilities, about capacity, about the space and time to decide to act, how to use those resources. This is the distributive ark of justice. And this is my thought on what Ozel actually said, which I really support and just an explanation of that thing in big organisations, managers, you know, distribute the resources, and they expect from us to have control over everything, without taking into account whether we have the capacity capabilities, the time, you know, pressures and things. And then when something doesn’t go, well, those expectations are not met, we have another process disengages from distribution of resources to come and a judge whether it was fair or not, we should be blamed or not, for what we delivered.
Nippin Anand 10:51
Interesting. So, the independents are the independent notion of of somebody coming in the space. And then and, and kind of trying to ensure that justice is delivered as part of this of this narrative is not very effective in this kind of situation. No, you don’t
capital, distributive and procedural justice, they will not, it’s never going to be enough.
Nippin Anand 11:22
The end, would you like to?
Diane-Chadwick Jones 11:24
Yeah, well, maybe I could say it in a different way. That what Nektarios just said, I do agree with also, that in small companies, it’s more likely to be applied more fairly, and in large companies less so. Now, why is that? Well, there’s there’s two reasons. I’m going to just say what, next year I said, But, but more simply, firstly, it’s about the mental model of incident causation. And secondly, it’s about the process that’s and the wording in the process that’s being used for just culture. So let’s talk about the mental model of incident causation. So if there is a view in a large company, that people are the problem, and that the amount of resources, as Nick TARIO says, are perfect, and everything’s perfect, and there’s no difference between how work we imagined work to be carried out, and how work is actually carried out, then when somebody makes a mistake on the day, they get blamed for it. And there’s a asking for accountability, especially because of the hierarchical levels in the organisation. In a small organisation, there’s less levels. So that’s the first thing, this mental model of the system’s view of incident causation or understanding that there’s many components, bringing the many, many witnesses that have to combine together to make an incident happen. Then the second thing is about the just culture process itself. So James reasons process that he published in 1997, uses criminal law language from Smith and Hogan 1975. It’s criminal law. And it’s reckless, negligent violation, all of those things. They’re priming the users to punish people. So So I’ve basically I’ve just brought what has already been said, a bit more to life. Because in BP, of course, what we did is we took that just cultural process, that was priming people through the language to to cause blame, and we changed it. And we turned it into questions. And we we took we took out the blaming language. And that made a huge difference to the level of learning, because then we were finding out what were the things that were getting in the way of people doing what we were expecting them to do.
Nippin Anand 13:49
Great point, can I ask you a question here, then? Yes. Is it the questions that made the difference? You think there wasn’t the language?
Diane-Chadwick Jones 14:00
So there’s two things one, there are a number of companies who helped us with the redesign, by the way, so slumber, Shea, British Airways. Obviously, you’re a control. Who hoo hoo said that. That a lot of it’s about training the users in the modern view of incident causation, the system’s view, that’s the first thing. The second thing is taking out the language of blame, net regular, reckless, negligent violation, and making sure that it’s not a flowchart that leads to focus on just one person. Somebody told us we needed to escalate and so we did escalate up the line rather than the last person to touch the valve. So so your question about language or questions, it’s yes change language. And yes, change the flow chart. out. So it’s questions. So you can have multiple answers rather than just being totally limited. And on top of that, the consistency of messaging within the company, the consistency of training, the leaders, that telling people to follow the rules, or you’ll be punished is just going to take us to a very bad place.
Nippin Anand 15:25
I’ll come back to that. But thanks, very interesting. Name. Would you like to offer your
Neil Richardson 15:29
thoughts? Yeah, sure. Some really good points made by by the entire team. And I think what I’d like to do really is decouple just culture from the word justice. I think it’s an easy link to make. But I think it’s a flawed one. And I think Nektarios mentioned the word expectations. And I think we should maybe focus on that a little bit more. Because the word justice, of course, conjures up all sorts of thoughts, you know, and some will instantly move towards a punishment type approach. And absolutely take Dion’s point about the language of reason. You know, it’s it’s quite inflammatory. I don’t deny that. I think equally, it’s been taken out of context a little bit, but the language does almost push you in that direction. I totally agree. You know, when you look at what he was saying, yes, violation, no one likes the word. But he did make the point. It wasn’t about bad people. It was about systems and learning. So there was that link already, in the words, but unfortunately, language didn’t necessarily convey that. So I’d rather talk about fairness and expectations and justice. I think that’s a better way to put this. And also, I’d like to decouple just culture from a process. And unfortunately, again, I call it that down flowchart, that flowchart has put people straight into a process mindset. And in my experience, most people that say they have just culture, don’t, they have a flowchart. And they have a process. And it’s easiest thing to create, it’s signed off by a regulator. And that’s it. And so we instantly think we’re doing just culture by then using that flowchart. Too often, it’s used after an event. Too often, it’s used to warrant punishment. And I often find that too often it’s used by untrained people on the back of a very, very bad investigation in the first place. So the interdependencies that wrap around that flowchart are themselves weak. And the flowchart itself is, but 1% of what we mean by just culture. Just Culture, for me goes back to that whole thing of creating the right environment, where we have a central sense of expectation between leaders, managers, and operatives. And we all buy into that for the purpose of talking about how healthy our system is, how what is it working, how is it not working, prior to an event. And if we don’t have that openness of disclosure, we can only react to bad stuff. So of course, that leads us to cultural change, and, and changing of people’s belief systems, which is not straightforward and easy. And I think that’s why we end up creating a process with all the other challenges and pressures that are also mentioned there. On the organisation. There is so much to do in modern day corporate worlds, that probably culture changes probably was one of the biggest things to be getting on with probably one of the last things that ever gets changed. And to add to that, I think as well that just culture itself can almost be bound by the organisational free framework itself when it actually needs to stretch beyond organisational boundaries. Because there are customers who want maybe to see punishment, there are suppliers who want to see it a different way. And so it’s it’s so much more than just internal to an organisation and and I think that’s a real challenge for any large corporation and even large industry.
Nippin Anand 19:00
Oh, yes, and in this instance, we have many instances where seafarers have to be sacked because of a charter is required because somebody feels very strongly the one who is who’s paying for the cargo if somebody feels very strongly that Seafarer acted unethical, exactly, yeah. Then made a very interesting point, which is both the language and the questions I think are equally equally equally important. And this is how you you cascade it to within the different levels of the organisation, but go in and output so I think I was interesting or share any thoughts from you listening to all the I
Oessur Hilduberg 19:43
I was fascinated by how Neil link the the almost confusion of terms when we talk about a specific kind of culture, namely adjust culture and then everybody’s talking about float arts and procedures and checklists and policies, and cultures, one could argue is a bit of a different animal culture than then this mechanistic, almost terroristic view on how organisations are being designed to work in a very specific way. Regardless, they’re working in completely different ways that we might expect that culture somehow detached from those instruments or to say, and then, obviously, procedures can be facilitators of culture, perhaps not. And that’s an ongoing discussion. But going into more depth on this just now, if we talking about some sort of sense of fairness and some sort of transparency of what just means in a given organisation, then perhaps, it’s not very beneficial to talk about culture, because it’s so diverse across an organisation, that in order to meet, to make a transparent process, to make it somehow predictable, to and also to distinguish between process and outcome, because when we talk about just and fairness is equally about the outcome, I am being punished yes or no, but also the transparency of what kind of process will I undergo before I reach that outcome? Thereby also, we would argue for having transparent procedures for what’s going to happen. But how does that relate to culture? per se? Really?
Neil Richardson 21:33
Yeah, yeah, sorry. I think that’s a really good point. And, you know, I think I think the, I think what we’ve got to be clear about is, is what are we trying to achieve with being just and what does that mean? Culturally? Yeah, I’m a very practical individual in that sense, you know, I, I look at the academia, and I never have to practically apply it in organisations. And, you know, for me, the way I tend to look at this is from, from from the very beginning of operations, and how people not only conduct themselves on a daily basis, but how they interact with others. What kind of disclosures do we have? How do we investigate as an organisation? Is it through fairness? Is it giving people the opportunity to be open and honest, and we treat them fairly? There isn’t this threat of blame over the top of them? You know, that’s all part of the fabric of the organisation. And and some may say, Well, that’s culture, that’s not but for me, it’s, can we see indicators of culture, I guess, is probably the best way to put that. And very simply, you know, things I tend to look for is, is when people are are raising their hand, is it? Is it after an event? Or is it before an event? So that’s one but one simple indicator of, of potential? A central sense of expectation? Yeah. Who do you find out from? Is it your own staff? Is it from your suppliers when the products you’ve worked on has gone elsewhere? You know, so there’s so much to to looking at indicators of culture, that’s the way I tend to look at it. Does that mean you’ve got a just culture in a box in a packet? Probably not. But it’s about moving that balance from from learning from bad things or reacting to bad things, and pushing the onus on the organisation to drive a mindset whereby we’re open and honest, and we’re disclosing potential for drift in the organisation. So we can get onto it beforehand. But that’s a that’s up against a very, very clear set of expectations that we lay down for the organisation. I don’t know if I’ve answered the question that I’ve said I was just adding that to,
Nippin Anand 23:48
oh, no, no, it is not about answering, it’s really about opening up the discussion, which is good. I think, if I understood your your point of is right, was that it’s almost impossible to to create a common understanding about a process, given the nature of the organisation, the competing interests, the individual values that people bring to the organisation. So I’m just thinking of your speaking. And that common understanding the shared understanding, isn’t that culture. Isn’t that what culture really means?
Oessur Hilduberg 24:25
Well, I could talk all day about different views on what culture means and sociologists and others anthropologists, they will discuss all day about that also. Now, there is this obviously, this is semi religious approach. In the most popular definitions of it, its commitments and beliefs and shared value stuff like that, which is and if you fall outside of that, you are a heretic somehow. So so there is this religious component to it, which is quite problematic. And arguably, they are different notions of what we believe in this company on different levels and so on. And therefore, this culture concept is really when we talk about it, we can agree on it, when we when we dive into organisations and making investigations of them, they have very little in common across these different levels, talking about a common culture is also quite difficult, except from received from the posters and marketing campaigns. Now, what am I having? Can we find commonalities? Well, perhaps, but what my what my interest was about was this just and the proceeds realisation of it and equally, so, if we have a, a disaster. So the the the impact that the the accident has on the organisation, can that somehow short circuit, the just culture procedure realisation there is? So it depends on how serious the event is, how much does it touch upon the self image the organisation has of itself? So, if we have minor incidents, yeah, we can deal with that, but change when when the seriousness of the accident changes, does that somehow change their mindset of what Justice shortcircuit these procedures?
Nippin Anand 26:22
I think Dan has something to
Diane-Chadwick Jones 26:23
say, yeah, it was a kind of a build upon what Osa and Neil was saying, and I’m sorry, I’m not going to ask answer your question or sorry about does justice change? Whether it’s the mistake cost $10 million, or whether it costs $10? And I know, in BP, we’ve really worked on that one, to make sure that it’s the same. Okay. But, but I do get your point. But where I was going with this was thinking more practically, rather than talking about well, what is or isn’t just cultural? What? What is culture? How do you know? If you have a just culture is a more useful question. And every company does standard annual surveys. And in every company, there’s the same question. I feel free to speak up without fear of retribution. And it goes to Neil’s point about, do you hear about things before the incident after the incident? And so therefore, the people who are listening to listening to this going to ask yourself, what what what do people actually say, on those large annual surveys that everyone has anonymous at? And if and if you’re 60%? Well, probably you don’t have a just culture there. Because it’s because people are just saying what they are answering what they think they should say. If it’s considerably higher than that, then maybe you do. But these are the, but really, there are a number of ways of looking at it. And that’s one way that you can straightaway, you can understand
a question for Dr.
Nippin Anand 28:20
Sorry. Yeah, I just wanted to share my thoughts then. And then notorious, you can you can chip in. You can always be sure that when people give a response to that answer the question that you just posed, it will be a very calculated response. So the question that you’re posing is very much at the level of rationality of the human being. And human beings are not rational beings. So what you will hear is a very rational calculated answer. Yes, it’s a very different situation. If you tell them, I need to know your answer in one second or two seconds. It’s a very different way. But I think we have to be very careful about the safety culture surveys, and the kinds of questions that we ask as a way to measure whether a belief system exists in the organisation or not. But that’s, that’s my view.
Diane-Chadwick Jones 29:07
Well, I get where you’re coming from. And I’ll explain why. Because safety culture surveys are very invasive. What I’m talking about is an annual attitude survey that happens every year that nobody pays any attention to. So I agree with what you’re saying with I totally disagree with safety culture surveys, because they have a Hawthorne effect. So Nektarios.
I really love the comment above this anonymity of the surveys and made me think about the anonymity of reporting systems. So, you know, do you think that this anonymity in the surveys and reporting system is by itself a signal that there is not just culture? Why should people join the surveys and sunbathing reports anonymously? If you’re happy just culture, then everyone shouldn’t be free to declare the name and the perception, the attitude of whatever you would like to ask the names
Nippin Anand 30:13
that’s a different discussion, but that it’s a good point, what I think we should bring back to the original question can process deliver justice, which is something that always has started off. Let’s let’s let’s try and go a little bit more deeper on that kind of process deliver justice in a large scale organisation. And we’re not even talking about just culture, because voice has just said that just culture is an oxymoron. They don’t exist. The two terms cannot coexist. I have a different view on that. But nevermind, it’s your day to day. So I’d like to
continue then on that Nippin Yes, no processes do not deliver anything humans deliver through the interactions with other humans in the system. processes can be there to facilitate things can be used cautiously within the context within the you know, within which they use. I fully agree with what you said before we have tried to standardise everything because we feel that standardisation means fairness, which actually sometimes it’s quite opposite. When we see one, you know, solution for everything. Then we miss the point there, yes, you can have a high level approach, I would say not a very, you know, a restrictive process. Because the procedural part of for large organisation might play a role just for some consistency. But at the same time, it does not mean we don’t have the room for humans to interact and put their thoughts there and ask Lane share at the state and then all together, see what they can get out of its situation. And the process should not always deliver a definite output. It’s just a process. Why do we focus on whether somebody should be punished or not at the end, because this is this preempts the goal of the process. So it’s the procedure to deliver that sculptural you is to find who to blame. So whereas these will be nil, or Nektarios, or Dianna, somebody should be blamed at the end of the process.
Nippin Anand 32:37
So we will expand on that. But sorry, somebody’s saying
Neil Richardson 32:43
something. Yeah, I’ll just gonna leave it there. Thanks. I think again, you know, it’s trying to try to decouple that that flowchart that flowchart thing, from from justice, and maybe the purpose of that flowchart hasn’t been fully understood by it by the industries that use it. I absolutely agree. And my experience shows me that when it tends to get used, it’s used inappropriately, it does facilitate blame. So people have gone through a just process, but they still blame somebody. But again, that was never really the intent of that flowchart. I know that one in reasons books, many, many moons ago, was almost the first iteration of some concept. And you see it, you see it in people’s manuals, I think we’ve moved on quite away from that. And there are other flowcharts out there that do a good job at trying to, to maybe deliver the intent of that flowchart. But, but again, it’s a tiny part of just culture. And, and that flowchart should only really be deployed in a tiny amount of circumstances. And I think that’s part of the problem that it’s almost rolled out as, as the just culture process. And so the purpose of that flowchart, the reasoning for it, and its rationale, and what it’s trying to deliver, in my experience is still very, very unclear. And there’s some comments on the right hand side there around, you know, what is just and everything else. But this goes right back to the point that reason was talking about, you know, the intent of humans and that variability. So today, we talked about human performance variability, and reasons spoke about intent. And really, the whole process that we have in that particular field, is just trying to bring clarity to the intent of someone’s decision making, was it unconscious? Was it conscious, and all that detail there? Because that helps to align to this set of expectations that we have. Yeah. And there’s a disconnect between the process and actually what we expect from our staff in the daily operation, and that’s part of the problem with disconnected safety and everything that goes with it from from daily operations. And so there’s no surprise We end up with this kind of confusion around what’s fair, what’s not, that the fairness of the organisation should include and acknowledge human performance variability. And that’s all inherent in that flowchart with and that’s often missed. In fact, in my, in my experience, it’s commonly missed and people use it as a blame tool
Nippin Anand 35:21
is Let me ask a slightly different question here. Process deliver an outcome that is not blame oriented, right. And we talk about individual systems. Can somebody tell me a story where you think that that was the case? That process actually delivered an outcome? That was? Yes, the idea? I would love to hear that.
Diane-Chadwick Jones 35:43
Yeah. So so we had the reason flowchart and it weepy. And it was linked to specific types of discipline. Okay. So just as Neil said, and what we saw was that was leading to blame. So we redesigned it, decoupled totally from discipline. And what we found was that, after a year and a half, we had 350 cases, that’s amongst 1000s. of issues. Okay, so rarely used. Okay, rarely use 350 cases, where most of them were system induced, caused by in clarity of procedures, issues with equipment, not enough resourcing. And what that did then, was it, it actually transformed the company, because you know, how our companies are they we love data, and the data made a huge switch, in the understanding of incident causation of the leadership of BP. And this is written up in an academic paper, this is not this is no secret, it’s actually written. This whole thing about how it transformed took us away from blame, took us away from holding people to account. And so that’s, and it remains the same. I mean, this was done in about 2012, and BP still on that track. So that’s a practical case study of a reality.
Nippin Anand 37:14
Let me just share an example with you, I’ve been an inspector on the ground for many years in auditor on the ground, I would go on board ships every day and start the audit with the, with the with the following ritual that I don’t, I don’t want to come and audit an individual here. I’m here to audit the system, right? And people will always almost laugh at me, what ridiculous statement are you making, because I don’t believe in what you’re saying at all. Again, the day you will blame me or you will blame somebody. So that is coupled with another thing, that when I was young as a child, my dad would often get mad at my mom, mom would get mad at me, I will get married, my youngest younger brother, and my younger brother would get mad at the dog, and the dog will start to scratch the surface on the ground. And the point being, I still struggled to understand that when we say we don’t blame anyone, it’s the system, there is somebody in the system that we are still blaming, somebody will still get hurt at the end of the day. So I’m intrigued by this idea of this dualism between the system and the human acts. Can somebody enlighten me on this?
Neil Richardson 38:28
I think trying to try to answer that it. We’re wired up to blame as human as a species, we’re wired up to blame. And I would slightly challenge that the view that we we blamed for error. And I think we blame for outcome. We see errors, and I’m going to use the word violations here just because it’s out there. I think we we don’t blame for that I think we blame only when it goes wrong or goes down a path we weren’t expecting. And that might cause disruption to the operation or damage to an asset or a human. I think that’s when blame comes in. And what we were trying to do 20 years ago with error management, as it was termed, is trying to turn that around a bit and look at the intent of a human. And of course, the intent of a human can be provoked, as Diane said, by the broader systems, there’s a connection there. So it was trying to get a shared responsibility to between the system performance and individual performance. And of course, we’re leaning towards the system, influencing humans. So why blame an individual who’s in a bad situation? And who is powerless to do something. But this notion that we blame for error, I think is slightly flawed. I think we only blame when we have an outcome that isn’t appropriate to our objectives. That’s when the emotions come out. Going back to Osias point that when it’s gone wrong, there’s an outcome and we want to blame someone and we’ve got to get away from outcome and look at intent intent of humans but for a systems lens And that, for me is where if just culture is applied correctly or created correctly, it gives us a better chance of doing that more consistently. I’m not going to say you’ll, you’ll have adjust culture, I think you’ll have a better chance of doing that more consistently. Does that helps
Nippin Anand 40:15
me, I see where you’re coming from? That’s a very Kantian view of duty bound view that at the end of the day, it’s about it’s about did you fulfil the obligations of your duty? And did you have the right intent? I’m still struggling to understand the connection between thinking about process as a way to deliver justice, and how that will ensure learning in an organisation which brings me to another discussion, which is how do we understand learning? What is your view on learning?
Neil Richardson 40:53
I can go if someone else wants to go first. Yeah. For me, again, it goes back to you know, it, there’s that there’s that what are we going to learn from? I’m going to spin that slightly? What are we going to learn from? You know, the traditional days, I’ll have an accident and learn. Okay, we all know about that. Do we truly learn? discus, that’s probably another debate for another day. But in terms of, or through the perspective of, of just culture? I believe it’s about what are we going to learn from what are we going to react to even as another way to put it, you know, are we going to wait for the bad accident or the bad outcome, or we’re going to look at signals of drift signals of of maybe subpar performance, and through the analysis of that come up with a decision to be made, that we can permeate through the organisation, managers, leaders, right down to frontline operatives? So I think it’s more a question of what are we going to learn from as opposed to are we learning of course, they’re part of the same, the same conversation, really. But that’s how coming back to just culture that was one of its main purpose is to create that upfront learning, or potential to the
Nippin Anand 42:09
Oh, yeah, I agree with everything you say, I would still go back to the same question. What is the Indian use that we have wonderful word mental model? And I think that’s, that’s, that’s a beautiful word. So let’s just ask everyone around the room to say, what is the mental model that comes to your mind when you think about learning what is learning?
Can I is on here. Learning this change to me, it’s not information is there as a saying, it’s not just talking this, when we hear now, we don’t learn actually, we just sit and we listen to each other, we get this information in now, where did this translate in to learning means translate into some form of chains. Although of course, in theory, we have different learning levels, cognition levels, and motor skills and so on. To me, if something is transmitted, it’s said, and, you know, remains in this sphere of information of data. Without using this information and data to change. Whatever necessary, then we haven’t learned. And sometimes I listen to thoughts and observations that we lose this corporate memory, and we don’t really learn from the past. No, because we never learned in the past, we just shared information through reporting systems. So in investigations, and we didn’t really redesign the systems, we didn’t change the systems, we just shared the information with everyone the the few corrective actions here and there without going deep and hard. And toughly, you know, into the system. And of course, those pathogens that remain there will manifest themselves in a year five or 10 from now. So I don’t think that we don’t have memory, organisational memory that much is that we don’t really learn when we have the opportunity to do so.
Diane-Chadwick Jones 44:23
I love this I love this idea of learning is change. And I would add just one thing and that is to look at the reality of work and then change I think that that is missed and that’s part of the issue with these just cultural ideas is that they’re not looking at the reality they’re not going deep enough and then doing change so I but I victorious I love that idea.
Neil Richardson 44:51
That’s a great point and Diane that that we can we can pretend we have a just culture and then we get the opportunity to learn we don’t we don’t look at the right things. And we go back to that kind of superficial investigation, put some stuff on the table. And I think it was also mentioned, you know, that complacency that’s, I cringe when I see that in an investigation, complacent. Of course, it’s easy thing to grab hold of, you know, either that or failure to follow procedures tend to be the top two human factors that always get drawn out the draw. Again, they’re indicators of maybe when that we’re not truly learning when we have the opportunity. So yeah, it’s a really good point, isn’t it that you can be just an enable people to talk openly and disclose things, but does the organisation and here’s the point, does the organisation truly want that because of course, to, to look deep into it soul creates work, it can cause reputational issues, it can actually cause massive disruption. So I think maybe leaders have to ask themselves the question, Do you truly want to just culture a real one? The prize is you can improve your system. If you don’t really want to go through the pain to get there. There may be what of course, some silence in techniques that give you a superficial just culture and you’ll carry on as under the banner of yes, we’re just here. But you’ll never learn.
Nippin Anand 46:15
Thank you. So you want to say something about learning?
Oessur Hilduberg 46:19
Well, I’m biassed by working in I have a background in the maritime business and these concepts and only work with them in maritime domains. And Charles Perrow characterise the maritime domain as an error inducing system. Now, in relation to learning, when I observe just culture, or just procedures, how just culture is conceptualised in the maritime industry, it’s completely detached from learning. It’s very much focused on accountability issues, and drawing lines and processes and so on. But learning is not really an integral part of it. And in the maritime domain, learning is very reactive. When I talk about the maritime domain, I’m I’m aware that there’s a large spectrum. But what I’m talking about is the what the maritime industry that occupies the middle ground that is very reactive. So they wait for reports to be made, and then learn from that. And as Neil pointed out, and you’re completely correct, if you do so left to synaptic reading of maritime accident reports, you read them in parallel, you will find something really peculiar, that if for any given type of accident, say collisions, occupational accident, surroundings, and so on. All accidents are caused by the same for the same reason. It’s the same conclusion for all of them, namely, complacency, lack of following procedures, some sort of professional norms being transgressed, and so on. So basically, all reports have the same conclusion, thereby also hindering this learning. But in lieu of, of having connected learning processes with just cultural processes, then it’s somehow short circuited. Which is really interesting for us. Thereby, there’s little learning going on, really, once arguably, the maritime industry is not at any pace, moving forward, on, on on safety, as much reactive as much if not more of the same more procedures, more bureaucracy, more very simple barrier thinking isolated to the specific incident, very little systemic thinking. LePen. You might you might protest if I’m, if this is an unfair characterization, broad characterization.
Nippin Anand 48:56
I guess you’re speaking and I’m thinking or is I’m still struggling with with an understanding of you say learning is change. What does that look like in practice? Some people say learning is improvement. What if we don’t improve? What if we don’t change? So where do we look for as practitioners? Are you under?
Oessur Hilduberg 49:19
Sorry? You said Oh, yeah. Oh, you unlearn that, that the process the very processes that you have for learning? It actually is a step back, right for what you’re doing is nobody says that you are becoming wise or maybe you are introducing new bad things to do. Yes, learning is not necessarily a positive. Meaning that that what we see when we investigate accidents that well intentioned improvements are the causes of the next accident, right. So and much of the learning is very related to a lot of not necessarily to make things Yeah, more effective. Perhaps but not necessarily more so.
Nippin Anand 50:02
And you know, what I would like to challenge everyone to think about is that think about Sally, does he want to learn? Do you think Captain Sally wants to learn? I mean, I’m, I’m being very controversial here, but I’ll do it anyway.
Neil Richardson 50:21
Do you mean from the particular event he was involved in?
Nippin Anand 50:25
Yes, I mean, per se from the Hudson Bay River Landing? What? What could an organism what what? What is learning? Then? What is the change that you will talk about it?
Neil Richardson 50:38
I guess what we will look at is, you know, what, we will try and stand back from that entire event from from, I guess, the time when it started to manifest itself and even probably before that, even beyond the time, and all the passengers have been retrieved off the aircraft. And, and even the, I haven’t seen the movie, but the the controversial part in the movie when he’s challenged by by the NTSB, allegedly, you know, for me that there’s it goes beyond the the bounds of the event and should stretch into the organisation or even the the National Climate potentially an even further, I guess, that’s a question of how far do you go back to learning? You know, where are the bounds of learning?
Nippin Anand 51:28
I’m being very concrete here. How do you convince somebody like Sully to learn? Because he, you know, he’s he’s is he’s a safety specialist. Now, he goes around lectures around the world. And I think he has some great things to say, how do we, how do we make sure that he also learns, and this is tied into the idea of there was a process there was a process, there was an investigation carried out, the the actual investigation had some clear outcomes work. So there was a process that delivered justice in the sense that he was not punished. Now. So how do you link? If that is the idea of just culture as a process to deliver justice, which is then tied in with learning? I’m just curious to understand.
Yeah, Nippin I think here we we make it dangerous Association. Delivering trust culture doesn’t mean that we absolve everyone from any error or mistake that somebody does not acknowledge that might have done things a bit differently next time or made a few misjudgments here and there, I mean, if just culture delivers a non blame, fortunately, you know, outcome, this does not mean that as a user, if I was part of this process, subjected to this process, that I don’t have the opportunities to learn. My, what was striking with this investigation with the Hampshire river thing is that, that in the beginning, instead of learning from the user, was trying to test whether the user the you know, those circumstances should have performed this way or not. So they didn’t first try to understand why made things made sense to the crew to act in a specific way, when we’re trying to do reverse engineering, say, under ideal conditions, you know, with the expectation that something would happen, how somebody else would perform, and if needed would perform better? What does it mean, for me? I’m not Neelam Nektarios, I’m not Diane, of course, somebody would make a different decision maybe would have a different angle, if here or the B trust or whatever. This means nothing. But I’m still Sally and Deborah Sally lens has the opportunity to learn from the process, regardless of the positive outcome.
Diane-Chadwick Jones 54:04
I think that’s a great point. Because just culture in general, the process is about looking at what made sense to people at the time. And so it takes us so much deeper, that if we did it after an incident investigation, and I’m just talking about the process here, we we we move on from complacency or didn’t follow procedure or lack of risk awareness. And we ask, well, was the procedure clear? Did they have enough resources? Was the equipment easy to use? Was it customer in practice, we ask those questions that then it’s about what makes sense to them at the time, and then you get the learning because you’re deeper, and you can actually make changes to that equipment or that procedure or that resourcing or that customer in practice. So that’s what you’ve inspired me there to say Nektarios
That’s great. Just one last thing here is that I will get back to the first point, you may die and about the mental model about how we approach causation of events. And I’m so tired of reading and listening to failure due to lack of, well, nature gates, vacuum and voids. So instead of saying failed to do something, let’s focus on what I was doing instead of what you expected. And why I was doing something different than what you retrospectively or by design you expect. It’s not lack of awareness, I cannot have like, I cannot lose my awareness. I was aware for something games than what we expected. So we need to understand where it was looking at. And why was looking? Yeah, yeah.
Neil Richardson 55:57
And in my experience, everybody, those conversations are not had enough, we tend to settle that first line of of conclusion if you’d like, the person didn’t do something. And that’s where a lot of investigations stop. And so I kind of reiterate my point earlier that I think we need to decouple the word just from justice, and move towards it a fair approach. And fair is about open honesty, transparency, disclosure, so that we can have the right conversations between people and get a sense of what’s going on in the reality of our operation, which was a Dion’s point. So yeah, unfortunately, it’s got a tag for justice attached to it. But um, yeah, I rarely talk about justice when it comes to just culture personally.
Nippin Anand 56:45
Great, we have four minutes left, and I would be very, very helpful if we can all summarise our reflections or thoughts. Before we end the discussion. It’s been it’s been very interactive. I’m so pleased with this very organic discussion that we had. But let’s start who’s who said wants to go first? What are your thoughts in closing? Please don’t take more than one minute because that would mean you take somebody else’s time.
Diane-Chadwick Jones 57:10
I’ll go first, very quickly. So let’s move away from this whole idea about justice and culture. Let’s think about fairness. And if you’ve already got a just culture process in your organisation, you really need to redesign it, and take out those priming words and educate your leaders on the modern view of incident causation.
Nippin Anand 57:40
Thank you, Dan. Very helpful. Nearly would you like to go on?
Neil Richardson 57:46
Yeah. Thank you. Just to add to Dion’s point, really about, you know, the word justice. I think I’ve said that now. And I think for me, taking a step back and asking yourself a question of why do we talk about this thing called just culture and what what is it truly if you’ve only got a flowchart and a process, that’s not just culture, this is a people focused systems focus. climate where people can disclose open honest information so that you can do things prior to an event. And that’s how I would summarise that.
Nippin Anand 58:22
Thank you, Neil. Notorious, you want to say next?
Yeah, my last thought is there’s no uniform line or threshold when we’re talking about a sculpture, whatever process or framework or procedure somebody follows, every case is different and must be evaluated within its context. So do you know when How do you know you have to just capture it every case is different. You know, indeed, when you learn, you actually become aware of what happened, not what didn’t happen, and why it happened. And taking this opportunity to change not the person who missed something or made the wrong decision based on your judgement. But all the factors around within the system that you have control over and you can change. That will be another way to see just culture.
Nippin Anand 59:28
Thank you, Nicholas. OSHA, would you like to offer your thoughts?
Oessur Hilduberg 59:32
Well, I’m thinking about two points. Number one is that just culture we need to be careful not to detach just culture from say, how we think about accident causation, how we think about systems thinking, how we view as our own organisation, not as a stable well functioning mechanistic machine that works well. Little something happens that we have problems and it’s unstable enough itself. And some things can happen. That’s a prior understanding we need to have before we can appreciate implementing any sort of just culture. That’s one issue. The second issue is, we see just culture concepts working quite well in terms of how fairness and transparency in some organisations, and what characterises them that they are small for instance, but also in larger organisations, it is when you detach just culture processes from the operational side, meaning that the person who is designing the procedures who is telling the operators what to do that we detach the just culture process from that and placing it somewhere else, say a job or even an outside consultancy company that would detach the the judgement of whether or not something was morally right or wrong to someone else. Not invested in it.
Nippin Anand 1:01:02
Great. There’s a lot to think about. But nail Dan voicer nectaries, thank you very much for your time. It’s been a wonderful pleasure and learning opportunity. And I reflect on it and come back to all of you. And those of you who are listening. Thank you very much for joining this session. I think it was a great summing up in a very, I will be trying to make it as as, as possible it could be to a crystallised question which was can process deliver justice. And again, how does that link with learning and what learning really means? There’s a lot to talk about it and think about it, and this entire series ahead of us, there’s at least four more sessions lined up. So we hope to see you again, once again. Thank you very much all of you.
Thank you for having us. Thank you.
Nippin Anand 1:01:58
Great. So what did you think? Let me summarise some of the key points that I took away from this conversation. I think the first thing to me is that perhaps it is inherent in the nature of an organisation that once it starts to expand, there is more reliance on processes and plans and standardisation. But then, the trouble is that the more standardised we make our processes the more formalised, we make our processes, the more it takes us away from human connections that we build with our colleagues, when we were a small scale organisation. And when we are left to processes and flowcharts to deliver justice and just culture, we experience quite the opposite, which is dehumanisation and injustice of people. And that’s what we heard. And I think that was quite powerful. Another perspective we hear is that when resources are finite, and we have to meet the fluctuating demands of work and organisation, there will always be times when the resources are not able to cope with the demands. So what do managers do? They’re very quick to judge and blame people when resources are not allocated to meet the needs of the business or business opportunities lots lost. So this alludes to the gap between work as imagined and work as done. And it’s a retributive approach to handle the gap in the face of an unwanted, undesirable outcome. So when things go wrong, and there is a problem with the resources because they were not allocated as we were expecting them to be, we are quick to blame people. Another approach that we hear is from today’s podcast is acknowledging that our language and the processes we have used traditionally are very retributive and punitive. And that changing the language and revising our processes will ensure a just culture. That’s an interesting perspective. From another perspective, we hear just culture is about aligning expectations across management, and amongst leaders developing a sense of understanding about the organisational pressures, demands, and how work is actually done. So that when things actually go wrong, our expectations are not too far away from the reality of the situation that confronts us. So in that sense, if we know already and we are in touch with how work is actually done the messy work, then we are not too surprised as a result of the failure. So to to apply. So in one way we are applying, or we learn how we can apply just culture to a non event, something that hasn’t happened. I think that was an interesting perspective offered by Neil also. Now, another perspective that I hear is that there is some tension or this is the actually one of the themes that there is some tension between whether a process can deliver justice, while some of the panellists think that we do not need a process. We do need a process but we need a different process, one that is embedded in restorative justice and learning As against a punitive language and approaches, while the others challenge the idea of a process and find it somewhat difficult to come to the term come to terms with the idea that a procedural violation can be understood using another procedure. That’s interesting, isn’t it? So that’s where the notion of just culture becomes a little bit problematic. Then we hear, talk about learning. And we think of learning as a change, which I find very interesting that my question really is, but what really is this change all about? What needs to change? Who needs to change? And is change even necessary is changing even a sensible proxy for learning? And so I’m left with more questions than perhaps answers, which is a very good thing. So our understanding of justice is still embedded in the difference between processes and reality, or as we say, work as done versus work as imagined. I don’t mind you there are multiple versions of what his work has done. But is that really what just culture is about? I can be opened up to more ideas about justice, like ethics, politics, humanising people, respecting people, listening to them, understanding them, empathising, with people and building relationships with them. Because how can we understand work has done from a personal perspective from from a person’s perspective, without having built trust and relationship with them? How will they offer us what they think they do, without us actually taking the time to build that connection? The other thing I felt was interesting was that we, we almost always tend to think of culture as a system. Is that really the same thing? I think it is not. But perhaps we need a little bit more clarity in the series as we go. And then we also need some clarity about what is the real meaning of learning, and that hasn’t come across so well so far. So what is learning how we do we know when we are learning when we when we cannot define learning? Well, so I think we need to in the episodes to come, we need to crystallise our thoughts on what learning means. So that was some of the reflections that I took away from this conversation. But I really want to hear your thoughts. I’m interested to understand your perspective about justice and safety. So please write to me at email@example.com, I’d be very delighted to hear from you. And by the way, before you go, for the first time in two years, we are actually planning on a live in person event in London, on learning organisations or learning culture on the 29th and 30th of June. details can be found on our website. So please join us if you’re interested in creating a framework for learning organisations. Steve Shorrock and I will take you through a range of practical tools and concepts, and we really look forward to seeing you in London. Details will be available on our website. But if you want to know more about the event, you can always write to us at firstname.lastname@example.org. Thank you