One of the strange things about the Just Culture phenomenon in risk and safety is the strange idea that somehow Justice and Culture can be controlled. Most often what Safety does with most things it touches is redefine Justice or Culture as ‘behaviours’. This is what Safety does with most things it touches even things such as Neuroscience somehow get reconfigured to mean behaviours (https://safetyrisk.net/safety-and-non-neuroscience/ ). The key to such redefinition is the quest for power and control.
The idea of Just Culture rarely defines either Justice or Culture very well. Most often ‘Just Culture’ is understood in safety as a blending of responsibility and accountability for behaviours.
The concept of Just Culture emerged in the history of safety in recognition of how Safety had evolved as a punishing-blaming activity. The concept was developed to shift the blame away from individuals on to systems so that one didn’t look for a person to blame but a system to blame. A tricky juggling act at best.
The general idea of Just Culture is to develop a culture where reporting can be open and behaviours can be confessed so that discipline can somehow be linked to a behaviour rather than the individual, despite the fact that individuals and groups enact behaviours. Of course, this is just spin so that the individual can be targeted in a new way without using the discourse of blame. However, Just Culture often means blame just wrapped up in Safety packaging.
The language of the Learning Organisation is often attached to the Just Culture discourse but whenever I undertake a Language Audit with executives in organizations the espouse Just Culture, none associate the notion of learning or helping with safety.
According to James Reason a Just Culture is a component of a safety Culture. Typical of Just Culture language is: ‘a culture in which frontline operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, willful violations and destructive acts are not tolerated’. (https://www.ioshmagazine.com/j-just-culture) So, see if you can work out what that actually means, good luck.
Associated with the Just Culture discourse (power in language) is also the idea of a ‘No Blame Culture’. Of course there is blame metered out under this banner and as such turns the Just Culture discourse into a slogan. Try and work this one out: ‘Just as a blame culture prevents us learning from events, so a no-blame culture can imply that, since no one is at fault, nothing needs to change’. (https://www.ioshmagazine.com/j-just-culture)
Others have reframed the language of Just Culture suggesting it should be ‘restorative culture’ or ‘fair culture’. However, the tension remains between one’s definition of Culture, Justice and the method one employs to tackle risk.
One of the things we can learn from a transdisciplinary approach to Justice is that Justice is part of a four way dialectic. One cannot consider Justice unless it is part of the Faith-Hope-Love-Justice dialectic. Isolating Justice from this dialectic tends to enable a discourse of brutalism in the name of good. We often see this when safety proposes that a Just Culture can be ‘engineered’ (https://flightsafety.org/files/just_culture.pdf ). This is similar to proposing that resilience can also be ‘engineered’. Such approaches come from redefining language such as ‘culture’ and ‘ethics’ as behaviours.
The dialectic of Faith-Hope-Love-Justice helps drive a holistic ethic that defines personhood as much more than just the sum of behaviours. This dialectic also helps get away from the naïve idea that people somehow know how to ‘do the right thing’, operate by received ‘common sense’ or ‘check their gut’ according to an ethic of duty – https://safetyrisk.net/the-aihs-bok-and-ethics-check-your-gut/ ).
The Faith-Hope-Love-Justice dialectic affirms several things:
· The certainty of uncertainty (Faith)
· The perseverance of flourishing life (Hope)
· The enduring devotion to being (Love)
· The ethics and politics of care (Justice)
The Faith-Hope-Love-Justice dialectic cannot be known via measurement neither by behaviours. Neither resilience, justice or culture can be engineered. None of Faith-Hope-Love-or-Justice can be measured and yet they are vital for living in the world ethically and politically. What tends to happen when Justice is pulled away from this dialectic is an ethic of utility. This is why the AIHS BoK chapter on Ethics is so problematic because it doesn’t discuss ethics, justice or zero.
When one cobbles together an ethic of duty and ‘check your gut’, the outcome is always brutality by whoever has the most power and the greatest investment in utility.
When your ideology is zero, the only outcome can be brutality. This is what is hidden in the discussion on Just Culture and of course zero receives no mention in the AIHS BoK Chapter on Ethics.
How on earth can there be justice based upon an ideology of zero? How can there be justice when the foundation of safety is intolerance? How can there be hope for fallible people in justice framed in the discourse of zero? How can one just ignore the ideology of zero as if the notion of justice is just about behaviours, when the policing of behaviours is the outcome of zero? Doesn’t the ideology of zero eliminate the need for Faith-Hope-Love in the exercising of justice? Doesn’t the ideology of zero just make the notion of Just Culture unjust?
Dr Rob Long
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Bruce says
Dear Rob, really appreciate your ongoing insights into life and humanity outside the safety bubble, no slogans and mantras, no trophies, holy grails and sacred cows, no pretentiousness. Showing not just the futility of imposing artificial one dimensional constructs, but enlightening on the harm of a system which ends up caring more for itself than the human beings it is supposed to protect, and actually championing a re-humanising view.
Rob long says
Thanks Bruce. So true. Love that quote ‘caring more about itself than the human beings it is supposed to protect’. You wouldn’t think one would be demonised for suggesting that safety should be human.
bernardcorden says
“The whole point of justice consists precisely in our providing for others through humanity what we provide for
our own family through affection”…..Lactantius
“When we are not sure, we are alive” – Graham Greene
I wonder what Nurse Mildred Ratched AO ChOHSProf thinks?
Rob Long says
I guess the most successful way to meter out zero is to hide it.