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Centro Studi Stasa

Just Culture

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Different points of view

There’s many a slip ‘twixt cup and lip

Note esplicativa…..The English proverb is almost identical with a Greek hexameter,

Πολλὰ μεταξὺ πέλει κύλικος καὶ χείλεος ἄκρου

“Much there is between the cup and the tip of the lip.”

“” A collective understanding of where the line should be drawn between blameless and blameworthy actions”” Just Culture as first defined by James Reason.

Just culture could be comprehended as a safety philosophy, it represents an atmosphere of trust, in which employs are genuinely encouraged, to report essential safety related issues; clear distinction would be made about of what is tolerable and what it is not. the effectiveness of the safety impact of reporting is strictly related to the company blame and consequences system.

The huge impact of J.C. on operational safety is clear and it is largely applied in aviation since 1990; Quality and quantity of safety reports directly affect the safety itself; J.C. enhance the chances of learning from mistakes, while improving the trust feeling toward the safety management.

From Aviation first, to healthcare, to many High reliability organization (HRO) environment, Just Culture approach largely broaden its success; The key point is to focus how theoretic this achievement remains. In many of those environment, it is developing a genuine trend to cope with this concern about blame-free attitude and the uneasiness of sharing; nevertheless it has to be pointed out that lack of practical means make it difficult to realize a proper safety gain from the J.C. approach.

Far from being easy to apply, in commercial aviation, J.C. is rather well accomplished in the western aviation, still a bit still academic in the middle east, and moderately unknown is the far East.. 

Disclosure of error is certainly worthwhile, and it does happen in a certain way, but still the actual voice of the frontline personnel is missing; plenty of recommendations are spread to reflect the company effort of encouraging the just culture, and to share report analysis;  frontline staff knows the error routine, the misleading  elements, the ineffective procedures, the bias, and all the condition that easily lead to errors; their voice is de facto either poorly demanded or poorly evaluated. In addition, evidence suggests that in frontline operations the punitive culture still has a role to play:  explicit reaction from the manager, subtle mobbing, rumors developing from peers… The most common blame culture is more likely to transpire in business that mainly rely on hierarchical, compliance-based structures; the J.C. philosophy is instead more likely to occur

where employee engagement is more effective; needless to say, human resource management capabilities play an important role in moving from a blame culture to a just culture.

 An appealing solution could come from the captivating philosophy well implemented in Japanese enterprise cultures, in particular at Toyota;

Toyota philosophy has become a model itself of great company management, offering great inspiration when it comes to explore business success stories; it manages to create the perfect JC environment; well known key point in Toyota philosophy could be summarized in the following (Magee David (2007), How Toyota became number one: Leadership Lessons from the World’s Greatest Car Company, New York, NY: Penguin Group):

  • Employee satisfaction is set as a priority: The right pursuit behind Toyota can be seen as a philosophy based on serving and respecting people, its employees, its customers and the wider public
  • Strive for continuous improvement (kaizen): encouraging problem solving at all levels of the organization, making management accountable to employees
  •  The power of humility: equality among workers (managers and non-managers). The traditional differences in importance between managers and non-managers are not observed at

Toyota. Workers live according to the philosophy of frugality, humility, and respect for each other’s.

  •  Improve quality by exposing the truth: Toyota workers have the responsibility to pull the cord immediately when problems are recognized: pulling the cord make the  the production line to stop; In Japan, any worker was encouraged to signal a problem by pulling the “andon cord,” (named after the Japanese word for a lantern), and management was willing to stop the line to ensure quality; In this way the workers feel trusted and empowered to take part in assuring quality, and this contributes to a culture that invites everyone to take pride in the plant’s output; in addition, management benefits from the knowledge and judgment of the workers. This means that the and on cord is an authentic mechanism for capturing ideas, for report errors or wrong procedures, not just a gesture of inclusion. creating the ideal Andon cord in the workplace to make sure everyone is encouraged to “pull” it when they think best.
  •  Let failure be your teacher: errors are viewed as opportunities for learning; following a mistake, an error or a noncompliance, the response is all about coaching, not shaming and punishing the workers. Leaders do thank people for pointing out problems
  • Manage like you have no power: The manner of “It´s me who´s in charge” doesn’t quite exist; it is rather just the opposite. The greatest sign of strength is when a employee, either a leader or a worker can openly address what has been the mistake, take responsibility, and propose countermeasures to prevent these things from happening again.

The challenge would be to measure how much more quality improvement would take place if that were the culture in our organization.

“Aim is to make it a tiny bit..

..(the ocean) between words and deeds