Ready, Fire Aim! Establishing a “Just Culture”

3 minute read

Today we pay tribute to the American workforce that built our nation.  It also reminds me of the many instances that my clients have nearly fired workers without properly analyzing the event or situation. In most cases, the work force at the sites that I support is largely comprised of the Trade Unions. I have walked into many cases where the relationships with these Unions ranged from “not the best” to downright “terrible.” when I look back at these instances, it was apparent in every case that the site had not established a “just culture.”

In his paper on “Just Culture: A Foundation for Balanced Accountability and Patient Safety,” Dr. Philip Boysen noted that in a just culture, the organization has to establish balanced accountability for both individuals and the organization responsible for designing and improving systems in the workplace. He goes on to say: “Just culture requires a change in focus from errors and outcomes to system design and management of the behavioral choices of all employees.”

In all my travels one particular story stands out. I was the Conduct of Ops Advisor and the Senior Supervisory Watch at a new Depleted Uranium Hexafluoride Conversion Site that was undergoing startup testing. A worker from one of the crafts was observed by the regulators overseeing the site to be working on a sensitive system without any paperwork; essentially doing something he should not be doing without the proper Work Controls to ensure the safety of the worker and the equipment. Site management’s reaction was to fire the worker, but the President of the company asked that they put any personnel action on hold until I reviewed the event.

Imagine a room full of Union workers and their Union Stewart with their arms crossed (and lips sealed) as I started to facilitate a causal analysis session on this event. As it turns out, this organization had a history of “Ready, Fire, Aim.” I think everyone knows what that means. What is not well understood is how taking such actions on the persons making an error or mistakes, without duly evaluating everything that happened, tears down an organization and creates the opposite of a just culture. It took a good half hour of talking college football, NASCAR, baseball and anything else that the group could relate to, before they started to participate in the analysis. Within a few minutes, they noticed that the more questions they answered (pursuing cause and effect analysis), the farther we were from the person that made the mistake of operating without a work order. Then, a miraculous thing happened: the Union voted to work through their morning break. Then they voted to continue working through their lunch break. By the time we were done around 1pm, we had uncovered a number of organizational and programmatic issues that needed to be addressed. At least one of those was an “error-likely situation” (i.e. where personnel are set up to fail).

When I presented my conclusions, the reactions from all sides was positive: management was satisfied that we got to the bottom of the issue and grateful we uncovered program weaknesses and gaps that they were anxious to address. The regulators were satisfied that the site took it seriously and proper actions were taken. But most importantly, the Union felt they were listened to, and that they were able to (in a analytical fashion) put forth their case for issues that were impacting their work force. In all, it was a WIN, WIN, WIN. But the biggest win for me was that the Union worker involved was reprimanded but not fired. In that instance, we created a “just culture” at that site. The response to this event set the tone for future responses to human error.

Interestingly enough, the whole investigation took two days. Not a huge investment in time but consider the impact: a family was not displaced because the main bread winner was fired (without any analysis); the labor Union did not feel persecuted; the regulators praised the organization for their thorough and measured response; and the management team got to improve the systems, processes and procedures that were creating the opportunities for other mistakes.

So this Labor Day, we pay our respects to the Trade Unions that built this country and continue to provide the skilled labor for so many projects, not just here in the United States, but world-wide. They all deserve the chance to work in a “just culture.”


If you would like to read Dr. Boysen’s article on Just Culture, the link is attached below. Although from the healthcare industry, the lessons are universal:

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