Creating a safe open learning culture

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Just Culture, Incident Reporting & Feedback Systems

A Just Culture - not a blame culture

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Mistakes are generally a product of faulty organisational cultures, rather than solely brought about by the person or persons directly involved.

In a just culture, after an incident, the question asked is, “What went wrong?” so we can learn to prevent a recurrence rather than “who caused the problem?” which simply leads to disciplining the nearest human to the error chain, which means those who witness or are involved in error keep quiet out of fear, and the fault repeats until the consequences become serious or catastrophic.

A just culture is the opposite of a blame culture. A just culture is not the same as a no-blame culture but is one where individuals are accountable for their wilful misconduct or gross negligence.

A safety culture consists of five elements:
  • An informed culture
  • A reporting culture
  • A learning culture
  • A just culture
  • A flexible culture

It encompasses;
  • Senior management commitment to safety
  • Realistic and flexible customs and practices for handling both well-defined and ill-defined hazards
  • Continuous organisational learning through practices such as feedback systems, monitoring, and analysis
  • Care and concern for hazards shared across the workforce

Industry-wide feedback & learning systems

At Ad Astra we are committed to the highest possible degree of safety across the industry and to this end we have developed a Safety Reporting and Feedback System that is open to all. It collates and anonymises safety reports and sends a monthly digest of reports and international incidents to all contracted organisations on a sector by sector basis. This is backed up by instant bulletins for critical issues.

It also attaches learning points and suggestions to all reports to prevent recurrences. In this way you avoid costly accidents and incidents that you were previously unaware there was a risk of.

You can see a sample page of the Ad Astra Incident reporting system here. We establish a separate system for each organisation and only collate de-identified data across particular industries for the monthly feedback bulletins. All data is secure and GDPR compliant.

Implementation & Support

We have implementation programs ready to go for all sectors of the economy and will work together with management and unions to ensure a seamless transition to a more just culture, for the benefit of all concerned.
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Our Just Culture flowchart shows where we all gain from the ability to report errors, incidents and accidents without fear, whilst retaining clear lines to isolate and deal with malicious or selfish actions. Mistakes don't get repeated, the act of management is no longer to punish colleagues for being part of an error chain, and those errors get eliminated.

Green outcomes are learning or training exercises, the red ones require action. All parties gain from accepting that humans are fallible and working to improve the system to avoid repetition.

Safety & Incident Reporting

What is a safety reporting system?

A Safety Reporting System (SRS) is a non-punitive, confidential, and voluntary program which collects and analyses safety reports submitted by personnel. Staff can report close calls, suggestions, and incident/event related information and data to improve safety.

It comprises several elements; a 'Just Culture', a free reporting system and a feedback/learning system.

Having a Just Culture permits the free flow of critical accident and incident data that gets hushed up in organisations with a blame culture. Why do we punish the person who has found a fault with the system or procedure? Learning from the mistakes of others gives us the opportunity to learn without risk and to close down vulnerabilities in our practices and equipment.
This makes management tasks easier as there remains a dividing line between accidental and deliberate and is empowering and popular with workforces who are released from the fear of being disciplined for being the victim of a systematic error.

The establishment of a just culture enabled the introduction of high fidelity safety monitoring for every flight (thousands of parameters, multiple times per second) with a data download each day and computer analysis looking for trends, areas of reduced safety margin and even 'accidents' that have yet to happen.

It was this combination of workforce trust together with an open self-reporting system that changed aviation from one catastrophe per week worldwide to an almost perfect safety record.

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Ad Astra Human Performance Ltd is accredited by the CPD Standards Office

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