From individual behaviour to system weaknesses: The re-design of the Just Culture process in an international energy company. A case study

• Published in: Journal of loss prevention in the process industries 2018-09, Vol.55, p.267-282
• Main Authors: Bitar, Fawaz K., Chadwick-Jones, Diane, Nazaruk, Marcin, Boodhai, Chan
• Format: Article
• Language: English
• Subjects: Culpability; Incident investigation; Just Culture; Modern view of incident causation; Safety culture
• ISSN: 0950-4230
• DOI: 10.1016/j.jlp.2018.06.015

The Just Culture (JC) process, originally introduced by James Reason (1997), remains a popular framework helping managers to decide how to respond in cases of human error or non-conformance which contributed to an incident. Our organisation started using Reason's framework in 2001. However, over the years, the available evidence indicated that the original design contributed to the misapplication of the JC process and in some cases led to outcomes not aligned with the intent. Several challenges associated with the framework itself, as well as its application, led to a re-design of the Just Culture process. This re-design moved away from Reason's original framework towards one informed by recent studies in cognitive and social psychology, organisational justice, systems thinking and incident causation. This paper describes how the middle level and senior level leaders, in the Upstream operations function, applied the Action Research approach to systematically understand the challenges associated with using a JC framework and addressed them through a modernised JC process. Our “re-designed” JC process consists of eight questions developed to be used after an incident investigation. These questions were intended to provide a lens through which leaders could better understand how to apply the findings and recommendations, and to resolve any underlying latent conditions that contributed to non-conformances, and to attribute accountability, if relevant. The cases are recorded in an electronic database and analysed periodically by our subject matter experts. 353 Just Culture cases were completed as of the end of October 2016. A summary of the analysis showed that approximately 90% of cases were attributed to system-level issues. The authors used the results of the Just Culture analysis to help shift the mind-set in the organisation and reinforce managers' understanding that most non-conformant behaviours are influenced by system weaknesses; strengthening employees' trust by emphasising that this is not a disciplinary tool; and encouraging a speak-up culture where the front-line staff feel able to raise concerns when non-conformances or error-producing conditions are observed. •Terminology and assumptions of the Reason's Just Culture framework were found as limiting successful implementation.•A new Just Culture framework is proposed based on the systems view of incident causation.•Careful selection and capability development of “who draws the line” is critical to