Operationalization of the 'Just Culture' concept in a Dutch Railway company

The concept of safety culture has gained much interest the last three decades, in scientific research and within organizations and industries. Although there is much discussion about a suitable definition of safety culture,... [ view full abstract ]

The concept of safety culture has gained much interest the last three decades, in scientific research and within organizations and industries. Although there is much discussion about a suitable definition of safety culture, there seems to be consensus that an important ingredient of a safety culture is the encouragement to speak openly about mistakes and learn from them. A ‘just culture’ strives for this, by balancing accountability and the ability to learn from failure. The paper gives insight in how theory about just culture is operationalized in a Dutch railway company, what the experiences are with the guideline and the effects on the safety culture in the company.

There are ‘just culture classification schemes’ developed (e.g. by James Reason) to help to judge if actions of individuals involved in an incident can be viewed as ‘acceptable’, ‘culpable’ or even as ‘reckless violation’. Sidney Dekker argues in his book Just culture (2007) that causes of incidents stem from a complex and subtle interaction of technical, organizational and individual factors. Because of that it seems not opportune to judge actions of workers involved in an incident by answering simple questions in a scheme. According to Dekker it is not about drawing a ‘fixed’ line between acceptable and culpable behavior beforehand, but about organizing the process of judgment and clarity about who draws the line.

To operationalize the process of judgment, in line with the view of Dekker, the railway company developed a ‘incident guideline’ and has two years experience using this guideline (especially for train drivers who experienced ‘signal passed at danger’ incidents). This guideline organizes the process of coming to a judgment and provides tools and background information. It separates three roles in the process of coming to judgment, an investigation role (assigned to the safety department), an advisory role (assigned to a advisory committee) and the decision role (assigned to management). In the committee different perspectives are gathered, a safety expert, a peer of the involved employee (for example a train driver), human recourses officer and a manager). To involve a peer in making a judgment is innovatory.

A key question that the committee has to answer is the ‘substitution question’: could a different person have made the same error or mistake under the same circumstances? This question is answered in relation to the complex contextual factors that played a role. If the substitution question is answered with ‘yes’, than the involved worker is immediately employable again. If answer is ‘no’, than targeted actions can be taken to solve the suspected issues the worker deals with (e.g. extra training or psychological assistance). To help the committee members to answer the substitution question, a document with background information and tips is included in the guideline. Evaluation results indicate that the guideline has a positive effect on the open culture that the company strives for.

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