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Just Culture


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Table of Contents

Contents: Preface; Prologue: a nurse's error became a crime; What is the right thing to do?; 'You have nothing to fear if you've done nothing wrong'; Between culpable and blameless; Are all mistakes equal?; Report, disclose, protect, learn; A just culture in your organization; The criminalization of human error; Is criminalization bad for safety?; Without prosecutors there would be no crime; Three questions for your just culture; Why do we blame?; Epilogue; Index.

About the Author

Sidney Dekker is Professor of Humanities at Griffith University in Brisbane, Australia. Educated as a psychologist in the Netherlands, he gained his Ph.D. in Cognitive Systems Engineering from The Ohio State University, USA. He has lived and worked in Sweden, England, Singapore, New Zealand, and the Netherlands. The author of several best-selling books on system failure and human error, Sidney has been flying the Boeing 737NG part-time as an airline pilot.


'Readers interested in organizational ethics and decision-making will benefit from the case studies and examples. Summing Up: Recommended. Lower- and upper-level undergraduates; general readers.' Choice, February 2013 ' is difficult to think of a more relevant and challenging book for health and safety practitioners, company managers and directors, regulators of all stripes, and members of parliament.' Safeguard, New Zealand, Jan/Feb 2013 Comments on the First edition (2007): 'Sidney Dekker's book is a thought-provoking exposition of the concept of a just society. Would that we could achieve it! The questions that the author raises need to be discussed at all levels of government, and by judges and lawyers, and by ministers of health. Dekker makes it clear that profound changes must be made in both the legal and the medical systems if we really wish to improve medical safety.' John W. Senders, University of Toronto, Canada 'A timely book about the current major safety dilemma - how do we resolve the apparent conflict between increasing demands for accountability and the creation of an open and reporting organisational culture? Thought-provoking, erudite, and analytical, but very readable, Sidney Dekker uses many practical examples from diverse safety-critical domains and provides a framework for managing this issue. A 'must-read' for anyone interested in safety improvement, but also, one hopes, for politicians, law-makers and the judiciary.' Dr Tom Hugh. MDA National Insurance Ltd, Sydney, Australia 'With surgical precision Sidney Dekker lays bare the core elements of a just culture. He convincingly explains how this desired outcome arises from a combination of accountability and (organisational) learning. The real-life cases in the book serve to drive his arguments home in a way that will be easily recognised and understood by practitioners in safety-critical industries, and hopefully also by rule makers and lawyers.' Bert Ruitenberg, IFATCA Human Factors Specialist The airline industry is under immense pressure and is full of sometimes serious contradictions. Staff are told never to break regulations, never take a chance yet they must get passengers to their destination on time. Staff are also implored to pamper passengers yet told not to waste money. The contradictions are at worst a receipt for disaster and at best low staff morale and lead to dishonesty as staff fear consequences and for good reason. Just Culture is essential reading for airline managers at all levels to both understand the endless conflicts that staff face trying to deliver the almost undeliverable and to reconcile accountability for failure with learning from that failure. A soul searching and compelling read.' Geoffrey Thomas, Air Transport World 'This book is both well-written and well-structured. It gives multiple perspectives on the complex issues of a just culture. The author greatly emphasizes on the down side of the blaming and punishing culture, and consistently proposes the new view of human errors. The given real examples make the points of the author very clear and applicable. The story-telling approach is definitely complementary with the stimulating questions of which the author uses as his writing style. Beginners and students in the human error field may benefit the most because this book is easy to read but without ignoring the significant details. Nevertheless, all of the professionals in high risk organizations and those who work in the name of justice may find this book as a thought provoking book and particularly as a guidance to build better safety systems where a just culture is practised.' Newsletter of the Europe Chapter of the Human Factors and Ergonomics Society, September 2008 'This book is fascinating because it is simply written and makes you understand the world of the judiciary and why "an honest mistake" can become a crime. A must-read for every regulator and Ops Manager if we want to retain our present incident reporting systems as a major contributor to safety.' The Controller, 2008 'HF/E practitioners bring a unique perspective to professionals operating in a particular setting, and this book makes compelling reading for anyone interested in complex social-safety environments.' Ergonomics in Design, Winter 2009 'It is unusual to find a book about a highly complex, brain-taxing subject which is not only enlightening but also a pleasure to read.' RoSPA Occupational Safety & Health Journal June 2009 '...this book could and should be read by the policy formers and decision makers of all medium and large enterprises. In doing so they will gain a great deal of insight into an area that has perhaps been neglected for too long. I cannot recommend this work highly enough.' Health and Safety at Work August 2009 'The author explains that unjust responses to failure are rarely the result of a bad performance; they are rather the result of bad relationships. He suggests that working on improving relationships between managers and employees, doctors and patients, the judiciary system and a profession, is one of the ways we could build a just culture.' Care Management Journal Vol 10 no 4 2009

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