Just Culture Framework

Reframing What Needs to Be Fixed

So, even if people are reckless or behave corruptly, RCA and systems thinking demand we understand the root causes that allowed, enabled or failed to stop people from behaving this way, or that failed to alert others to what might be happening.

Table 10.2 Just Culture – Action Options (illustration of possible responses).

	At an individual level	At an organisational level
Human error	Individuals should be counselled or coached, but not punished.	Processes should be improved (including automation if appropriate). Consider extra training or improved supervision, etc.
‘Risky’ behaviour	Individuals should be engaged to clarify why they made the decisions they did.	As above, but also taking steps to identify spin‐off problems from any stretch targets and to implement measures so staff are less likely to take inappropriate risks (e.g. risk adjusted incentives).
Reckless behaviour	Disciplinary action likely to be appropriate.	As mentioned above, but also work on behavioural risk factors and improve process checks and balances to prevent such behaviour if possible.
Malicious, corrupt or fraudulent behaviour	Disciplinary action, and quite possibly legal proceedings, (subject to evidential questions)	Ensure efforts on anti‐fraud activities, anti‐bribery and corruption, whistleblowing, anti‐retaliation, etc., are fully effective.

The framework may evolve as practice develops.15

Consider the Barings bank collapse, which many people associate with what the ‘rogue trader’ Nick Leeson did. Such a perspective ‘zooms in’ on a key person, and clearly he was guilty of wrongdoing. However, if you look at the results of the inquiry into the Barings collapse, you will also find a ‘zoom out’ perspective, speaking about organisational shortcomings as well.16

‘Barings’ collapse was due to the unauthorised and ultimately catastrophic activities of … one individual that went undetected [because] of a failure of management and other internal controls of the most basic kind.

Management failed at various levels and in a variety of ways … to institute a proper system of internal controls, to enforce accountability for … profits, risks and operations, and adequately to follow up on a number of warning signals over a prolonged period.’

In other words, identifying intentional wrongdoing does not complete the root cause analysis: we must also ask how the organisation allowed it to happen.17

The power of the just culture framework is that it accepts the possibility of lapses, mistakes, errors and risky behaviour, and reminds us that you can't blame people for being human. However, it does draw a line so that intentionally reckless or malicious behaviour is appropriately punished.

Andrew Wright offers an early experience coming across a just culture approach to a production quality problem:

‘I recall an occasion when an audit of work identified quality problems we were doing for a large aviation company. A technician had started using the wrong glue in the assembly of a specific component for the plane's wing. When it was discovered that there was a specific guy who got this wrong, our initial reaction was to discipline him and move him into a less high‐profile role.

But when we discussed this with the aviation company we worked with they said: “No, absolutely not! He is the person we want doing this task because he now knows just how big a deal it is if you get this wrong. Our experience in this sort of situation is that it's unlikely he will make such a mistake again. In fact, he can be a quality ambassador for other colleagues, so they realise how much their work can matter”.

Of course, we didn't stop our quality control and quality assurance, but I remember sensing a huge cultural difference between us and the aviation company. And I could see subsequently how even this single example created a greater sense of openness with staff working on the factory floor.’

With the just culture mindset, we are wary of rushing to judge the actions of others. This runs contrary to the way many news stories, crime novels and TV detective series discuss ‘bad behaviour’. Often, in the media and fictional accounts, writers take great interest in understanding the motives of evildoers and hunting down the people who should be punished so the rest of us ‘good folk’ can get on with our lives.

While the desire to single out and punish a ‘bad actor’ is both understandable and can be wholly appropriate in some circumstances, RCA and systems thinking encourage us to see the context within which people operate that may affect their actions. Perspectives on the causes of crime and corruption (in the real world and fiction) also explore the existence of grey zones (such as apparent inequities) and the way others might look the other way, rather than seeing things in good and evil, black and white, terms.

Discussions about misogyny and racism also draw attention to (i) the role passive bystanders can inadvertently play in supporting bad behaviour, (ii) shortcomings in whistleblowing mechanisms and (iii) weaknesses in investigations intended to get to the bottom of allegations of wrongdoing.

So, overall, the aim is to deliver appropriate discipline and sanctions at an individual level when it's merited, but also to learn and improve things at an organisational level as well.