Just Culture
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.
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3recommend
6mentions
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2018–2025years
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Mentions per year
What Hacker News says
- This 1000 times. It takes courage to open up to mistakes. As a relatively young industry, we have a lot to learn still to move away from the instinctive blaming culture surrounding such failures. In this case, it's only a file being downloaded a couple of times, nobody died or got injured.
For those interested in this topic, and how other industries (e.g. Airline industry) deal with learning from or preventing failure: Sidney Dekker is the authority in this domain. Things like Restorative Just Culture, or Field guide to understanding human error could one day apply to our industry as well: https://sidneydekker.com/books.
- Exactly. See Sidney Dekker's Field Guide to Understanding Human Error. The posters do (almost) nothing -- other than covering the backside of those who put them up, and doing safety theatre. Looks good, does nothing for safety.
The same author, Sidney Dekker, has a very good book about how to deal with someone like this whistleblower. It's called "Just Culture". Well worth a read. Spolier: It's not to silence them, not this way. You can silence the person by, you know, actually doing something useful. But that requires actual change, and more importantly, a change in attitude. And you need to convince the crowds that you are doing better by NOT putting up posters. You'll be surprised how many people really think the posters help.
- My current box of books that I recommend to new managers on my teams:
Technology Specific:
* An Elegant Puzzle: Systems of Engineering Management (Will Larson)
* Accelerate: The Science of Lean Software and Devops: Building and Scaling High Performing Teams (Nicole Forsgren, Jez Humble, and Gene Kim)
* Team Topologies: Organizing Business and Technology Teams for Fast Flow (Matthew Skelton and Manuel Pais)
* Empowered: Ordinary People, Extraordinary Products (Marty Cagan)
* The Phoenix Project (Gene Kim, Kevin Behr, George Spafford)
General:
* The Goal (Eliyahu Goldratt)
* Turn the Ship Around! (L David Marquet)
* Just Culture (Sidney Dekker)
* Leadership on the Line (Ronald Heifetz, Marty Linsky)
* Emotional Intelligence (Daniel Goleman)
- The whole society is getting short-changed by the idiots trying to make a sacrificial goat out of her/him. Anybody who doesn't understand why s/he doesn't talk, should read Sydney Dekker's books (in particular, "Just Culture -- Restoring Trust and Accountability in your Organisation"). We need the NTSB to do the investigation, they are non-blaming and serious professionals concerned about the FUTURE not the PAST -- i.e. making sure it doesn't happen again.
I seriously want to give a hug to the person who mis-clicked. If you have seen that UX design, you know as well as anyone else, that indeed, most would have mis-clicked over time.
The people investigating this are making a huge mistake.
- The book I still have open is actually by Sidney Dekker - "Restorative Just Culture in Practice: Implementation and Evaluation". A quote:
> In 1066, with the Norman invasion of England, William the Conqueror and his successors brought into existence a legal system that gradually replaced the church and local systems of conflict resolution. For the nascent state, the legal system turned out to be useful for exerting influence and extracting money. Crimes were seen not (just) as violations of a community’s mores, or the victim’s rights. They were seen as infractions against the state, and against the ruler, the king, as a disruption of the ‘King’s peace’. Fines benefited the ruler economically and often politically. The state and the offender were the primary actors around whom the justice was organized, and the victim played a lesser role.
- "Just Culture" by Sidney Dekker is a book about balance between fairness/justice and learning how to prevent incidents in the future. He doesn't have a lot of good things to say about the court system.
https://www.amazon.com/Just-Culture-Balancing-Safety-Account...
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