Human Factors and Just Culture
Human factors thinking emphasizes that people are not root causes of incidents; their mistakes often stem from systemic issues. A 'just culture' balances accountability with understanding human variability to avoid scapegoating.
THE IDEA
Summary
- Remember, a person is not a root cause, even if they deliberately did something wrong.
- People make mistakes for all sorts of reasons, many of them quite innocent.
- The fact that a person's response to a process step or procedure is not 100% in line with the process or procedure is not always a problem; processes and procedures are not always perfect and they may not address every eventuality that can arise in practice.
- Human variability is part of the human condition because we are not robots or clones. Sometimes human variability has positive outcomes.
- It's the inability to identify and adjust to human factors that is a causal factor (something that management needs to consider and address appropriately), not the human factor itself.
- The ‘just culture’ framework seeks to balance holding people accountable and disciplining them with an acceptance of potentially innocent human variability where people should not be scapegoated.
- Aviation and other High‐Reliability Organisations embrace Human Factors thinking and just culture. Still, it takes ongoing effort to make sure this is properly understood and applied in practice.
- The identification of ‘cultural’ and ‘tone at the top’ problems can be useful to ensure Human Factors thinking examines all parts of an organisation. However, a ‘poor culture’ and a ‘poor tone’ are not root causes in themselves.
- Despite the importance of many standard HR activities (selection, performance management, and training and development), there can still be critical cracks in, for example:
- Recruitment – in relation to cognitive diversity;
- Senior leader knowledge and understanding of certain technical areas;
- Senior management understanding of ‘the basics that matter’ in finance, governance, IT, and other compliance and control‐related matters.
- The ‘fit and proper’ tests for senior managers that have become mainstream in financial services are likely to be worth considering in other contexts and sectors.
- Group dynamics in meetings is an area that can be easily neglected in organisations.
- Organisational politics is another area that is overlooked in many organisations. Unfortunately, political animals are often present and work hard to stay ‘below the radar’.
- The Canadian CPA document on the oversight of risks at the board level is to be commended, as is the Walker review on board effectiveness (notably the discussion on group dynamics).
- Political behaviour often seeks to find scapegoats, a mindset that runs entirely contrary to an RCA and systems thinking mindset.
When to use it
Investigating an accident in aviation or healthcare to avoid scapegoating and focus on systemic improvements.
Evaluating a financial loss to identify systemic weaknesses and assess individual accountability without looking for a convenient scapegoat.
Improving board effectiveness by focusing on group dynamics and cognitive diversity in recruitment.
Designing performance management systems that account for human variability and do not penalize innocent mistakes.
FROM THEORY TO EVERYDAY LIFE
In practice
Pilot Error in Aviation
An airline pilot makes an error during landing. An investigation reveals fatigue, poor checklist design, and inadequate training, not pilot negligence. The just culture approach focuses on fixing systemic issues rather than punishing the pilot.
Trader Breaching Risk Limits
In a financial firm, a trader exceeds a risk limit. The root cause is found to be a flawed risk model and pressure from senior management to generate returns. The trader is not scapegoated; instead, the risk management process is improved.
A MOMENT TO REFLECT
Put it to work.
How can your organization move from blaming individuals to understanding systemic factors when incidents occur?
What mechanisms exist to identify and address cultural and tone-at-the-top issues without treating them as root causes?
How can group dynamics in meetings be better managed to reduce the influence of 'political animals' that seek scapegoats?
Often confused with
References
- Oversight of Risks at the Board Level — CPA Canada
- A Review of Corporate Governance in UK Banks and Other Financial Industry Entities — David Walker (2009)
CONTINUE THE CONVERSATION
Source texts
- Beyond the Five Whys Root Cause Analysis and Systems Thinking (James C. Paterson)