Work has never been as safe as it seems today. Safety has also never been as bureaucratized as it is today. Over the past two decades, the number of safety rules and statutes has exploded, and organizations themselves are creating ever more internal compliance requirements. Bureaucracy and compliance now seem less about managing the safety of workers, and more about managing the liability of the people they work for. … We make workers do a lot that does nothing to improve their success locally. And paradoxically, the tightening of safety bureaucracy robs us of exactly the source of human insight, creativity, and resilience that can tell us how success is actually created, and where the next accident may well come from. (Introduction to The Safety Anarchist (2018) by Sidney Dekker)
Sidney Dekker is a Professor at Griffith University in Brisbane, where he runs the Safety Science Innovation Lab. He is also a part-time Boeing 737NG airline pilot. He describes Restorative Just Culture in this way:
A just culture is a culture of trust, learning and accountability. In the wake of an incident, a restorative just culture asks: ‘who are hurt, what do they need, and whose obligation is it to meet that need?’
It doesn’t dwell on questions of rules and violations and consequences. Instead, it gathers those affected by an incident and collaborates on collectively addressing the harms and needs created by it, in a way that is respectful to all parties. It holds people accountable by looking forward to what must be done to repair, to heal and to prevent.
Dekker distinguishes two views of human error:
Old View: Human error is a cause of trouble, complex systems are basically safe:
- Explaining failure means you must seek human failures (errors, violations, incompetence or mistakes.)
- Identify people’s inaccurate assessments, wrong decisions, and bad judgments.
- Restrict the human contribution by tighter procedures, automation, and supervision.
New View: Human error is a symptom of trouble deeper inside a system, complex systems are NOT basically safe:
- Finding out how people’s assessments and actions made sense at the time, given the circumstances that surrounded them.
- Complex systems are trade-offs between multiple irreconcilable goals – such as safety and efficiency
- Safety in complex systems is created by people through practice.
The Impact of Human Drift on Standards or Norms of Behavior
Every couple of weeks a YouTube video is posted showing a fire department operation that goes wrong or leaves you cringing. Dekker (2006) points out that, if we conduct an investigation of that event, it is a snapshot of the progression of a drift from an original norm or standard in that fire department.
The success that just culture has within aerospace, healthcare, and other industries with catastrophic potential outcomes is identifying and managing the inevitable drift in human behavior.
The challenge is that what goes wrong usually goes right. Over time organizations can come to think that a safety threat does not exist or is not too bad.
For example, the fire department standard requires that apparatus maintain more than a half-tank of fuel. The norm has drifted to a quarter-tank of fuel.
As the incoming shift starts their morning check, Engine 4 is dispatched to fire in an apartment building under construction. Engine 4 is flowing a master stream and supplying a ladder pipe … until it runs out of diesel early in the operation. It had 1/8th of a tank of fuel at shift change.
An effective safety culture in a complex system is a like the practices described within Crew Resource Management, the boss needs to hear the bad news
In The Safety Anarchist (2018) Dekker describes the ineffectiveness of the safety bureaucracy, the manipulation of things that get measured and the infantilization of smart adult workers. His recommendations in pushing back on compliance and bureaucracy to improve safety and organizational resiliency include these:
- Promote safety as a shared, guiding principle
- Build connections between people across your department and authority-having-jurisdiction
- Create capabilities for self-organizing
- Eliminate safety posters and slogans
- Permit pride of ownership
- Facilitate novelty and diversity
- Create the conditions for intrinsic motivation to blossom
Dekker’s key takeaway is that courage, commitment, communication with stakeholders and a bit of time can eliminate 90% of a safety management system paperwork and related bureaucracy while improving safety conditions at work.
Dekker, Sidney (2006) The Field Guide to Understanding Human Error, revised edition. Burlington VT: Ashgate Publishing Company. ISBN 0 7546 4826 5 (PBK)
Dekker, Sidney (2018) The Safety Anarchist: Relying on Human Expertise and Innovation, Reducing Bureaucracy and Compliance. New York NY: Routledge. ISBN 978-138-3004-0 (PBK)