Just Culture Accident Model

At the time I wrote this I was working with various methods to investigate accidents. I have since found that Leveson’s STAMP provides the most robust method.  This paper may be useful in a technique to help the field investigator focus on the context of why a person did what they did, but after that I believe STAMP should be applied.  The abstract follows:

This paper proposes that the concepts developed for Just Culture may provide an avenue to broaden the scope of accident investigation and move away from the “blame” outcome of most reports through the use of a simple Just Culture algorithm to mitigate cognitive bias on the part of the investigator. Absent a formal strategy, cognitive bias has a high probability of occurring, and becoming integrated into the investigators subconscious during the early stages of an accident investigation. Just Culture is becoming widely accepted, and as such the transition to integrating an investigative model utilizing the concept should be easier to implement and may encounter less political push back than some of the more complex approaches proposed in recent years, yet still provide a robust path to causality and human factors aspects that is more comprehensive than that offered through the traditional models that are still in use by most organizations.

Click here to view the conference paper.

Advertisements

About Shem Malmquist FRAeS

B-777 Captain. Air Safety and Accident Investigator. Previous experience includes Flight Operations Duty Officer, Assistant Chief Pilot. Line Check Airman, ALPA Aircraft Technical and Engineering Chairman, Aircraft Performance and Designs Committee MEC Chair, Charting and Instrument Procedures Committee, Group Leader-Commercial Aviation Safety Team-Joint Safety Implementation Team (CAST)-Loss of Control-Human Factors and Automation, CAST-JSIT- Aircraft State Awareness. Fellow of the Royal Aeronautical Society, full Member of ISASI, AIAA, IEEE, HFES, FSF, AFA and the Resilience Engineering Association.
This entry was posted in Safety. Bookmark the permalink.

One Response to Just Culture Accident Model

  1. Performance Discipline

    It is an inescapable fact that the causation of most, if not all, harm from adverse events includes failures to consistently and systematically act in accordance with known good practice. “Performance Discipline” is consistently and systematically acting in accordance with known good practice.

    Performance Discipline is not a call for the use of “best practices”, but merely a call for known good practices, practices that are known to have resulted in satisfactory performance outcomes.

    Observation: A vital part of Performance Discipline is known good practices, practices that are known to have resulted in satisfactory performance outcomes.

    Observation: Since “discipline” has several meanings, careful professionals mention that Performance Discipline is the consistent and systematic acting in accordance with known good practice when they use the term.

    Observation: The essence of performance discipline is the same worldwide and for all activity endeavors, but the details differ due to differences in situations and practices. “Performance Discipline” is consistently and systematically acting in accordance with known good practice.

    Observation: Although there is certainly more to the story, the causation of the crash that killed singer John Denver involved multiple opportunities for Performance Discipline in his conduct of the final flight of his newly purchased Long E-Z aircraft . “Performance Discipline” is consistently and systematically acting in accordance with known good practice.

    Observation: The causation of the lack of performance discipline involves deeper harmful conditions, behaviors, actions, and inactions. “Performance Discipline” is consistently and systematically acting in accordance with known good practice.
    The lack of performance discipline is never a “root cause.”

    Observation: The causation of the 2015 ExxonMobil Baton Rouge Release and Fire , an example of workers whose competence , training, supervision, and instructions were jointly insufficient to avert deaths, involved multiple barrier issues, including work planning, pre-job briefs, job safety analysis, referring to drawings, worker task qualification, workarounds, and the like. Each barrier deficiency was the result of a set of harmful conditions, behaviors, actions, and/or inactions. This event was a poster child for ignoring Performance Discipline.

    Observation: Known good practice includes simple businesslike compliance with applicable provisions of government requirements, industry standards, industry guidelines, local training, labor agreements, purchasing documents, and the like.

    Observation: Known good practice includes instructions, procedures, and drawings that are known to be appropriate to the circumstances because of their previous recorded use.

    Observation: Known good practice includes practices documented in recorded results of post-job debriefs (PJDs), after action reports (AARs), and the like.

    Observation: A known good practice can cover a major activity such as overhauling a piece of equipment or it can cover a lesser aspect of the activity such as planning, initial conditions, disassembly, management of disassembled components, reassembly, or the like.

    Quotation: ”Visualize-Verbalize-Vitalize.”-Unknown for now

    Quotation: “Plan your work and work your plan.”-Old Navy Chief Petty Officer Wisdom

    Quotation: “Failing to plan is planning to fail.”-Worker Wisdom

    Quotation: “Never take your ship anywhere your brain hasn’t already been.” Navigation Wisdom

    Quotation: “When you see something dumb, dangerous, or different, speak up.” Fire Service Wisdom

    Quotation: “It’s hard to tell what’s wrong if you don’t know what right looks like.”-Bill Corcoran

    Lesson to be Learned (LTBL): Much harm is averted when task teams follow prescribed business practices. Much harm results from intended and/or unintended departures from the prescribed business practices. When sponsoring organizations know the involvement of business practice departures and their causations, corrective actions can often be taken.

    Quotation: “Say what you do. Do what you say. Prove it. Improve it.”-ISO 9000 Principles

    Quotation: “Stop-Think-Act-Review (STAR)”-Nuclear Power Wisdom

    Quotation: “Plan-Do-Monitor-Adjust (PDMA)”-Bill Corcoran

    Quotation: “Drive a stake through the heart of the problem; don’t just prune the poison ivy.”-Bill Corcoran

    Quotation: “Attend to the culture or be meat for the vulture.”-Bill Corcoran

    Quotation: “If you want safety, peace, or justice, then work for competency, integrity, compliance, and transparency.”-Bill Corcoran.

    Lesson to be Learned (LTBL): Part of Performance Discipline is the ability to document that every participant in the activity and/or task is competent to perform their roles and duties in the activity and/or task.

    Quotation: “Informality often precedes fatality.”-Bill Corcoran.

    Recognized and Generally Accepted Good Investigative Practice (RAGAGIP):
    The event investigation report should include a discussion of each and every missed opportunity to have improved the harmful outcomes of the event by consistently and systematically acting in accordance with known good practice, often called “Performance Discipline.”

    Observation: A strong safety culture will include Performance Discipline, i.e., consistently and systematically acting in accordance with known good practice, in its mental content, artifacts (physical objects), institutions, and norms.

    Observation: Safety culture is the part of culture that involves safety. A culture of safety is an entire culture that emphasizes safety. All organizations have a safety culture. Few organizations have a culture of safety.

    Observation: Performance discipline culture is the part of culture that involves performance discipline. A culture of performance discipline is an entire culture that emphasizes performance discipline. All organizations have a performance discipline culture. Few organizations have a culture of performance discipline. “Performance Discipline” is consistently and systematically acting in accordance with known good practice.

    Observation: It is highly likely that if the test program for the Gulfstream 650 had included performance discipline lives and property would have been saved . “Performance Discipline” is consistently and systematically acting in accordance with known good practice.

    Observation: An asset owning organization that acts as if it does not understand performance discipline is setting itself up for asset losses as in the case of the Sinking of S. S. El Faro in a Hurricane .“Performance Discipline” is consistently and systematically acting in accordance with known good practice.

    Observation: When performance discipline is an ingrained endemic organizational value it is not sacrificed or compromised by pressure of any kind. “Performance Discipline” is consistently and systematically acting in accordance with known good practice.

    Observation: Both the ABSG Investigation of Black Elk West Delta 32 , which fingered the subcontractors and the government investigation that found Black Elk at fault contain multiple situations in which Performance Discipline would have saved lives and assets. “Performance Discipline” is consistently and systematically acting in accordance with known good practice.

    Observation: The causation of the Accidental In-Port Launch of the Sting Ray Torpedo included the lack of performance discipline. “Performance Discipline” is consistently and systematically acting in accordance with known good practice.

Comments are closed.