Captain Sullenburger, who so successfully landed an Airbus A320 in the Hudson river, left behind a library copy of Sidney Dekker's 'Just Culture' on the sinking plane.
New York City Mayor Michael Bloomberg yesterday presented him (and his colleagues) with the keys to the city and also a replacement copy of the book. A just culture protects people's honest mistakes from being seen as culpable. But what is an honest mistake, or rather, when is a mistake no longer honest? It is too simple to assert that there should be consequences for those who 'cross the line'. Lines don't just exist out there, ready to be crossed or obeyed. We-people-construct those lines; and we draw them differently all the time, depending on the language we use to describe the mistake, on hindsight, history, tradition, and a host of other factors.What matters is not where the line goes-but who gets to draw it. If we leave that to chance, or to prosecutors, or fail to tell operators honestly about who may end up drawing the line, then a just culture may be very difficult to achieve.The absence of a just culture in an organization, in a country, in an industry, hurts both justice and safety. Responses to incidents and accidents that are seen as unjust can impede safety investigations, promote fear rather than mindfulness in people who do safety-critical work, make organizations more bureaucratic rather than more careful, and cultivate professional secrecy, evasion, and self-protection. A just culture is critical for the creation of a safety culture. Without reporting of failures and problems, without openness and information sharing, a safety culture cannot flourish.Drawing on his experience with practitioners (in nursing, air traffic control and professional aviation) whose errors were turned into crimes, Dekker lays out a new view of just culture. This book will help you to create an environment where learning and accountability are fairly and constructively balanced. About the Author Sidney Dekker (Ph.D. The Ohio State University, 1996) is Professor of Human Factors and System Safety and Director of Research at Lund University School of Aviation in Sweden. Author of Ten Questions About Human Error (Erlbaum, 2005) and the top-selling Field Guide to Understanding Human Error (Ashgate, 2006), he has been appointed as Scientific Advisor on Healthcare System Safety to the Winnipeg Regional Health Authority in Canada, and is visiting professor in the Department of Epidemiology and Preventive Medicine at Monash University in Melbourne, Australia. Just Culture: Balancing Safety and Accountability - Buy this Book from Amazon here