Our special column focuses on a book written by Sidney Dekker that offers new material on restorative justice and ideas about why people may be breaking rules.
This third edition of Sidney Dekker’s extremely successful ‘Just Culture’ clarifies that a just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong.
Supported by extensive case material, Mr. Dekker aims to provide clarity about safety reporting and honest disclosure, about retributive just culture and about the criminalization of human error. “Some suspect a just culture means letting people off the hook. Yet they believe they need to remain able to hold people accountable for undesirable performance,” the author notes.
In this new edition, the author asks the readers to look at accountability in different ways. One is by asking which rule was broken, who did it, whether that behavior crossed some line, and what the appropriate consequences should be. In this retributive sense, an ‘account’ is something that gets people to pay, or settle.
Another way to approach accountability after an incident is to ask who was hurt. To ask what their needs are. And to explore whose obligation it is to meet those needs. People involved in causing the incident may well want to participate in meeting those needs.
Anyone interested in organizational ethics and decision-making will benefit from the case studies and examples the book is presenting, as it is more relevant and challenging for health and safety practitioners, company managers and directors, regulators of all stripes, and even governments.
Lessons learned from past incidents show that the main causes to human and organizational errors are:
- The crew’s fatigue
- Insufficient communication
- Lack of technical knowledge or poor knowledge of the ship’s systems
- Automation faults and poor maintenance
- Uninformed decisions and following of the wrong standards and procedures
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