SH03: HF for Dummies. Part 3. Just Culture.
Part 3 of the Dummies series. This one is looking at Just Culture and why we need it in order to learn.
In this episode, we unravel the concept of a Just Culture in the context of Human Factors and its critical role in facilitating learning from mistakes. We start by clarifying the notion of culture, emphasizing its subjective nature rooted in fairness. Contrary to common misconceptions, a Just Culture is not about assigning blame but about understanding what went wrong and why individuals made certain decisions.
We illustrate this with two poignant examples: the MV Conception sinking and a tragic diving incident in the UK. In both cases, a deeper examination of the system and circumstances, rather than immediate blame, led to valuable lessons and, in some instances, legal outcomes that diverged from initial perceptions.
We underscore the importance of asking "How did this happen?" rather than "Who is to blame?" and advocate for a shift in language and culture within the diving community to foster a shared belief in learning from incidents and enhancing safety.
Original blog URL: https://www.thehumandiver.com/blog/hf-in-diving-for-dummies-part-3-just-culture
Links:
National Transportation Safety Board accident report
https://www.ntsb.gov/investigations/AccidentReports/Reports/MAR2003.pdf
Press reports on the “out of gas” incident
https://divernet.com/scuba-news/hung-jury-discharged-in-stoney-manslaughter-trial/
https://divernet.com/scuba-diving/diving-instructor-cleared-in-safety-stop-death-case/
Information about IPO
https://www.bsac.com/news-and-blog/the-hidden-killer-immersion-pulmonary-oedema-ipo/
Gareth’s blog on InDepth about Just Culture
Tags:
- English Dummies Incident Analysis Incident Investigation Incident Reporting Jenny Lord Just Culture
