A 'Just' Culture is not a 'Just Do It' Culture

Those who have read many of the blogs on The Human Diver will recognise the term “a ‘Just’ Culture” but recent research I have conducted has indicated that there is some confusion about what this means to those in the diving community. This blog will hopefully address this so that we can continue to learn from the mistakes we and others make by being able to talk about them in a manner which helps learning, and not blaming. 

What is a ‘Just’ Culture?

A ‘Just’ Culture was originally defined by Professor James Reason in 1997* as “an atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour”. The idea being that we know human error is normal, and that to punish someone for making an ‘honest’ mistake would do nothing for organisational learning because the events would be hidden.

However, there was a concern that if there was a ‘no-blame’ culture, then workers would exploit the situation and not be accountable for their poor decisions. By having a ‘line in the sand’ these ‘lazy’ workers would then not bring down the productivity or safety reputation of the company, because HR could deal with them accordingly.

A ‘Just’ Culture is primarily an organisational ‘thing’ to help organisational learning by ensuring that when something went wrong, a complete account of what happened could be captured and then analysed. The problem is that what is acceptable or unacceptable can really only be determined after the event, and it is normally the leadership who decide this. In the case of diver training agencies, it will be the quality control department, or in a dive centre, the manager of the facility. In both cases, these individuals are often unsighted as to the real challenges of delivering training, not understanding the gaps between what should be taught ('work as imagined') and what is actually done ('work as done') because of the commercial and resource challenges that are faced. This presentation from the HF in Diving Conference in September 2021 describes the messy world of diving, and the trade-offs that exist when delivering training.

There is also a conflict at the organisational level: if the diver training organisation accepts that such trade-offs happen and standards can’t be maintained, then when it comes to litigation following an adverse event, the plaintiff will hold them accountable (tell the story) and responsible (do something about it) to fix something that is potentially unfixable. The easy solution is 'more rules', however, if the rules don't take into account the context, or there is no real way of enforcing them, then they just add to the 'safety clutter' that is out there.

Recent research has shown that while aviation has wholeheartedly embraced a ‘Just’ Culture as a way of improving safety, and put regulations in place to support this (e.g., EC 374/2016), there are problems because of the conflict between the legal aspects of justice and the organisational aspects, and what is considered ‘gross negligent’ is not consistent between different countries, the law, and the companies. 

From the previous paragraphs, we can see that ‘Just’ is about being fair and just, as in the context of justice. However, in the real world, the problem lies not with the concepts of acceptable and unacceptable but who draws it, as our judgements are clouded by hindsight bias, outcome bias, the fundamental attribution bias, and societal pressures to show that ‘justice’ has been delivered. Justice for whom? What does fair mean? Fair to the diver, the instructor, the families of those involved, the dive centre, or the training agency. Perspectives change the fairness of something.

What is a ‘Just Do It’ Culture?

Data I have seen recently indicates that a considerable number of divers think that a ‘Just Culture’ means a culture of 'just doing it', getting the job (dive) done without thinking about the consequences. This could be down to a mixture of different things, but certainly not in the spirit and meaning of a ‘Just' Culture which is about creating the circumstances where learning from near-misses, incidents, and accidents can happen by telling context-rich stories.

• Normalisation of deviance or normalisation of risk: There is a gradual shift in the perception of something going wrong because nothing has gone wrong in the past and the margins for error are gradually eroded until something adverse happens. Such drift is normal human (and organisational) behaviour and it requires consistence standards (and reference back to them) to reduce the impact. This links with the next item. 

• What are the drivers that are leading to the diver, instructor, manager or agency staff to make the decisions they do? Financial pressures, time pressures, social pressures, poorly designed/maintained equipment, and lack of understanding of risks by students/clients can all make it harder to adhere to the standards. There is a need to look at the system, not the ‘errant’ individuals if the same issues are being encountered. 

• ‘Bad apples’ or ‘bad’ day? It is easy to judge those who have had a ‘bad’ outcome because we can see it. Unfortunately, we often focus on the outcomes, judging far more harshly when something severe happens compared to the same decision process but a lesser outcome e.g., running out of gas and making a rapid ascent after a diver is task-loaded compared to a diver who surfaced with just less than minimums and was equally task-loaded but their buddy picked up that they were low on air when they looked over at their SPG. They were lucky… If a DM didn’t check that everyone was onboard because their captain gave them additional work to do which distracted them, is that an individual issue, or a system one? Did they have a 'bad day'? If we require perfect performance as the barrier between success and failure, we have a weak and fragile system that WILL fail at some point, and then it is the poor person who was last to touch that is blamed even though the system (cheese) is full of holes all over the place!

 
What about the sports diving sector? Where does Just Culture fit in?

Sport diving is an adventure sport. No matter what any training agency will say, there is an inherent and irreducible risk of injury of death involved. Once divers are outside the training system, there is limited duty of care applied to those taking part in the activity. Divers are both responsible (doing) and accountable (telling an account) for managing the risk and uncertainties involved. However, this can only be done if the cognitive biases that we use to make these decisions (recall bias, recency bias, sunk cost fallacy, distancing-through-differencing, and social conformance) are understood, and that means the telling of stories where success and failure has occurred. For that to happen, we have to have a culture where stories, warts and all, can be told. That is the essence of a Just Culture but without an organisational input.

How to 'create' a Just Culture?

One of the challenges is that it is difficult to intentionally create a cultural change, as the culture is embedded in the actions, behaviours, artefacts (images/stories/equipment/language) of those within the culture. Each sub-community e.g., cave, recreational, CCR, European, Floridian, Mexican... will have its own culture. A recent open study in healthcare has looked at how to develop a Just Culture in a healthcare (Trust) setting and these are the key points that have emerged from that.

• Define an agreed vision of what Just Culture means to the organisation. This will be a problem for diving operations outside of an organisation.
• Introduce incident management familiarisation training. There is no formal structure concerning incident management, incident investigation, or the application of human factors in investigations in diving.
• Increase face- to- face communication of outcomes of investigations and incident review. This is linked to the prior recommendation. There is a need to develop a structured investigation process that looks at genuine learning rather than pointing at the individual diver or instructor when something goes wrong.
• Establish an incident investigation team to improve the timeliness and consistency of investigations and the communication and implementation of outcomes. As above...!

The need for an investigation process has been covered on a number of occasions in the past, but there doesn't appear to be any interest...

Summary 

A Just Culture is essential if we are to be able to learn from the mistakes we make. We are never going to be able to make them all ourselves. We might verbally tell these stories within our close group of divers/friends so that we can learn, but I can guarantee that the mistakes made by one team in Vancouver will be same that are made in England, and are the same in the UAE, and the same as in Australia. Therefore, we also need to be able to learn from others’ mistakes.

The culture has to change towards one of learning from others, where we look for similarities when unexpected events happen, not the differences. We are all human and we are all wired pretty much the same way, and that means the errors and adaptations that we make are broadly the same. Consequently, the learning happens not from trying to stop making an error, but rather an understanding of the context in which the error or adaptation took place is critical. That means we need to tell context-rich stories, and that is impossible if people think that they are going to be punished for doing so…

References:

Managing the Risks of Organisational Accidents. Reason. 1997. Page 196.

Just Culture "Dummies' Blog on The Human Diver 

Just Culture 'tag' on The Human Diver Blog

Is a Just Culture needed to support learning from near misses and diving accidents? - InDepth

Gareth Lock is the owner of The Human Diver, a niche company focused on educating and developing divers, instructors and related teams to be high-performing. If you'd like to deepen your diving experience, consider taking the online introduction course which will change your attitude towards diving because safety is your perception, visit the website.