Promoting Fair and Just Culture in Incident Investigation
Fair and Just Culture emphasizes using an objective approach to analyzing incidents, determining root causes of errors, and taking corrective actions to prevent future occurrences. Human failures, such as slips or mistakes, can create holes in safety barriers, but addressing unsafe behaviors through re-education and reinforcement can help mitigate risks. A structured decision tree guides organizations in handling incidents fairly and justly, distinguishing between intentional actions, system-induced errors, and blameless mistakes.
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WHAT IS A FAIR AND JUST CULTURE The concept of Fair and Just Culture , is about using a consistent approach The concept of Fair and Just Culture , is about using a consistent approach and interpretation of the facts relating to an incident investigation. and interpretation of the facts relating to an incident investigation. Using objective analysis rather than an subjective opinion to establish the Using objective analysis rather than an subjective opinion to establish the root cause of any human error. root cause of any human error. To ensure the correct actions are taken to prevent reoccurrence of the event To ensure the correct actions are taken to prevent reoccurrence of the event Care: first priority, second nature
An individual person becomes the last barrier between the hazard and a situation where all barriers are lined up Incident Hazards Organisational controls Leadership / Supervision Tools and Equipment Safe behaviour
HOLES IN THIS LAST BARRIER ARE CAUSED BY HUMAN FAILURES Slips Skill-based errors Lapses of memory Errors Rule-based mistakes Mistakes Human failures Knowledge-based mistakes Routine Violations Situational Exceptional What factors contribute to these human failures ??
ADDRESSING UNSAFE BEHAVIOUR Slips Re-design workplace/ practises Skill-based errors Lapses of memory Errors Rule-based mistakes Re-educate workforce Mistakes Human failures Knowledge-based mistakes Routine Reinforce Violations Situational leadership Exceptional
FAIR AND JUST DECISION TREE Care: first priority, second nature
YES YES Follow Drugs and Alcohol Policy Drugs and alcohol test positive ? Individual actions ? Incident Hazards NO Apply disciplinary policy Were the consequences intended (Potential or actual injury or plant and /or equipment damage ? YES YES Sabotage , malevolent damage , suicide , etc . Were the actions intended ? ) NO NO YES Possible reckless violation . Procedures available and well communicated Employee trained and audited , intelligible YES Knowingly violated safe operating procedures ? ? ? NO System induced violation . NO NO Possible negligent error e.g. slip , lapse or mistake , . Substitution test employee with same training and experience have done the same : Would another NO Deficiencies in training and or experience , selection ? ? YES System induced error . YES Blameless error Training , counseling consider suitability for job . YES , . History of unsafe acts ? NO Blameless error . Identify SYSTEM failures
This person deliberately YES YES Follow Drugs and Alcohol Policy caused the outcome Drugs and alcohol test positive ? Individual actions ? Incident Hazards NO Apply disciplinary policy Were the consequences intended (Potential or actual injury or plant and /or equipment damage ? YES YES Sabotage , malevolent damage , suicide , etc . Were the actions intended ? ) NO NO YES Possible reckless violation . Procedures available and well communicated Employee trained and audited , intelligible YES Knowingly violated safe operating procedures ? ? ? NO System induced violation . NO NO Possible negligent error e.g. slip , lapse or mistake , . Substitution test employee with same training and experience have done the same : Would another NO Deficiencies in training and or experience , selection ? ? YES System induced error . YES Blameless error Training , counselling , consider suitability for job . YES . History of unsafe acts ? NO Blameless error . Identify SYSTEM failures
Despite all audited YES YES Follow Drugs and Alcohol Policy efforts, this individual still did what they should Drugs and alcohol test positive ? Individual actions ? Incident Hazards NO Apply disciplinary policy Were the consequences intended (Potential or actual injury or plant and /or equipment damage ? YES YES Sabotage , malevolent damage , suicide , etc . not have done Were the actions intended ? ) NO NO YES Possible reckless violation . Procedures available and well communicated Employee trained and audited , intelligible YES Knowingly violated safe operating procedures ? ? ? NO System induced violation . NO NO Possible negligent error e.g. slip , lapse or mistake , . Substitution test employee with same training and experience have done the same : Would another NO Deficiencies in training and or experience , selection ? ? YES System induced error . YES Blameless error Training , counselling , consider suitability for job . YES . History of unsafe acts ? NO Blameless error . Identify SYSTEM failures
YES YES Follow Drugs and Alcohol Policy Drugs and alcohol test positive ? Individual actions ? Incident Hazards NO Apply Not all barriers were disciplinary policy Were the consequences intended (Potential or actual injury or plant and /or equipment damage ? Sabotage , malevolent damage , suicide , etc . in place, the systems that protected people were not effective YES YES Were the actions intended ? ) NO NO YES Possible reckless violation . Procedures available and well communicated Employee trained and audited , intelligible YES Knowingly violated safe operating procedures ? ? ? NO System induced violation . NO NO Possible negligent error e.g. slip , lapse or mistake , . Substitution test employee with same training and experience have done the same : Would another NO Deficiencies in training and or experience , selection ? ? YES System induced error . YES Blameless error Training , counselling , consider suitability for job . YES . History of unsafe acts ? NO Blameless error . Identify SYSTEM failures
YES YES Follow Drugs and Alcohol Policy Drugs and alcohol test positive ? Individual actions ? Incident Hazards There was no intent, but others would not have behaved this way, and NO Apply disciplinary policy Were the consequences intended (Potential or actual injury or plant and /or equipment damage ? YES YES Sabotage , malevolent damage , suicide , etc . despite training and being suitable for the job this undesirable Were the actions intended ? ) NO NO YES Possible reckless violation . Procedures available and well communicated Employee trained and audited , intelligible YES Knowingly violated safe operating procedures ? ? System induced violation behaviour still happened ? NO . NO NO Possible negligent error e.g. slip , lapse or mistake , . Substitution test employee with same training and experience have done the same : Would another NO Deficiencies in training and or experience , selection ? ? YES System induced error . YES Blameless error Training , counselling , consider suitability for job . YES . History of unsafe acts ? NO Blameless error . Identify SYSTEM failures
YES YES Follow Drugs and Alcohol Policy Drugs and alcohol test positive ? Individual actions ? Incident Hazards NO Apply disciplinary policy Sabotage , malevolent damage , suicide , etc . There was no intent, but others would not have behaved this way, however part of this is Were the consequences intended (Potential or actual injury or plant and /or equipment damage ? YES YES Were the actions intended ? ) NO NO YES Possible reckless violation . Procedures available and well communicated Employee trained and audited , intelligible YES Knowingly violated safe operating procedures ? ? ? NO System induced violation because training and selection were not . NO NO Possible negligent error e.g. slip , lapse or mistake adequate , . Substitution test employee with same training and experience have done the same : Would another NO Deficiencies in training and or experience , selection ? ? YES System induced error . YES Blameless error Training , counselling , consider suitability for job . YES . History of unsafe acts ? NO Blameless error . Identify SYSTEM failures
YES YES Follow Drugs and Alcohol Policy Drugs and alcohol test positive ? Individual actions ? Incident Hazards NO Apply disciplinary policy Were the consequences intended (Potential or actual injury or plant and /or equipment damage ? YES YES Sabotage , malevolent damage , suicide , etc . Were the actions intended ? ) Everybody does it like this because of custom and practice or because we NO NO YES Possible reckless violation . Procedures available and well communicated Employee trained and audited , intelligible YES Knowingly violated safe operating procedures ? ? ? NO System induced violation train it like this, but this person has done this kind . NO NO Possible negligent error e.g. slip , lapse or mistake of thing before so they need to be talked to , . Substitution test employee with same training and experience have done the same : Would another NO Deficiencies in training and or experience , selection ? ? YES System induced error . YES Blameless error Training , counselling , consider suitability for job . YES . History of unsafe acts ? NO Blameless error . Identify SYSTEM failures
YES YES Follow Drugs and Alcohol Policy Drugs and alcohol test positive ? Individual actions ? Incident Hazards NO Apply disciplinary policy Were the consequences intended (Potential or actual injury or plant and /or equipment damage ? Sabotage , malevolent damage , suicide , etc . This person does follow all the YES YES Were the actions intended ? ) NO NO YES Possible reckless violation . rules and standards, and is Procedures available and well communicated Employee trained and audited , intelligible YES Knowingly violated safe operating procedures ? ? ? NO System induced violation in line with other colleagues, but . NO NO Possible negligent error e.g. slip , lapse or mistake unfortunately sometimes , . Substitution test employee with same training and experience have done the same : Would another NO Deficiencies in training and or experience , selection ? ? YES System induced error unexpected things happen . YES Blameless error Training , counselling , consider suitability for job . YES . History of unsafe acts ? NO Blameless error . Identify SYSTEM failures
