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B and S == BS

About a year ago, after a recommendation from management guru Tom Peters, I read Sidney Dekker’s “Just Culture“. I mention this because Nancy Leveson dedicates a chapter to the concept of a “just culture” in her upcoming book “Engineering A Safer World“.

The figure below shows a simple view of the elements and relationships in an example 4 level “safety control structure“. In unjust cultures, when a costly accident occurs, the actions of the low elements on the totem pole, the operator(s) and the physical system, are analyzed to death and the “causes” of the accident are determined.

After the accident investigation is “done“, the following sequence of actions usually occurs:

  • Blame and Shame (BS!) are showered upon the operator(s).
  • Recommendations for “change” are made to operator training, operational procedures, and the physical system design.
  • Business goes back to usual
  • Rinse and repeat

Note that the level 2 and level 3 elements usually go uninvestigated – even though they are integral, influential forces that affect system operation. So, why do you think that is? Could it be that when an accident occurs, the level 2 and/or level 3 participants have the power to, and do, assume the role of investigator? Could it be that the level 2 and/or level 3 participants, when they don’t/can’t assume the role of investigator, become the “sugar daddies” to a hired band of independent, external investigators?

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