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Swiss Cheese Model

swiss cheese slice

The Human Factors Analysis and Classification System—HFACS

Cover and Documentation
1. Unsafe Acts
2. Preconditions for Unsafe Acts
3. Unsafe Supervision
4. Organizational Influences

HFACS and Wildland Fatality Investigations

Hugh Carson wrote this article a few days after the Cramer Fire

Bill Gabbert wrote this article following the release of the Yarnell Hill Fire ADOSH report

A Roadmap to a Just Culture: Enhancing the Safety Environment

Cover and Contents
Forward by James Reason
Executive Summary
1. Introduction
2. Definitions and Principles of a Just Culture
3. Creating a Just Culture
4. Case Studies
5. References
Appendix A. Reporting Systems
Appendix B. Constraints to a Just Reporting Culture
Appendix C. Different Perspectives
Appendix D. Glossary of Acronyms
Appendix E. Report Feedback Form

Rainbow Springs Fire, 1984 — Incident Commander Narration

Years Prior
April 25th
Fire Narrative
Lessons Learned

U.S. Forest Service Fire Suppression: Foundational Doctrine

Tools to Identify Lessons Learned

An FAA website presents 3 tools to identify lessons learned from accidents. The site also includes an animated illustration of a slightly different 'Swiss-cheese' model called "defenses-in-depth."

A Roadmap to a Just Culture:
Enhancing the Safety Environment

Prepared by: GAIN Working Group E,
Flight Ops/ATC Ops Safety Information Sharing

First Edition • September 2004

2. Definitions and Principles of a Just Culture

2.1 Definition of Just Culture

According to Reason (1997), the components of a safety culture include: just, reporting, learning, informed and flexible cultures. Reason describes a Just Culture as an atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior (See Figure 1).

A “Just Culture” refers to a way of safety thinking that promotes a questioning attitude, is resistant to complacency, is committed to excellence, and fosters both personal accountability and corporate self-regulation in safety matters.

A “Just” safety culture, then, is both attitudinal as well as structural, relating to both individuals and organizations. Personal attitudes and corporate style can enable or facilitate the unsafe acts and conditions that are the precursors to accidents and incidents. It requires not only actively identifying safety issues, but responding with appropriate action.

SAFETY CULTURE INFORMED CULTURE Those who manage and operate the system have current knowledge about the human, technical, organizational and environmental factors that determine the safety of the system as a whole. REPORTING CULTURE An organizational climate in which people are prepared to report their errors and near-misses. JUST CULTURE An atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior. FLEXIBLE CULTURE A culture in which an organization is able to reconfigure themselves in the face of high tempo operations or certain kinds of danger – often shifting from the conventional hierarchical mode to a flatter mode. LEARNING CULTURE An organization must possess the willingness and the competence to draw the right conclusions from its safety information system and the will to implement major reforms.
Figure 1. Based on Reason (1997) The Components of Safety Culture: Definitions of Informed, Reporting, Just, Flexible and Learning Cultures

2.2 Principles of a Just Culture

This section discusses some of the main issues surrounding Just Culture, including the benefits of having a learning culture versus a blaming culture; learning from unsafe acts; where the border between “acceptable” and “unacceptable” behavior should be; and ways to decide on culpability.

Evaluating the benefits of punishment versus learning

A question that organizations should ask themselves is whether or not the current disciplinary policy is supportive to their system safety efforts.

  • Is it more worthwhile to reduce accidents by learning from incidents (from incidents being reported openly and communicated back to the staff) or by punishing people for making mistakes to stop them from making mistakes in the future?
  • Does the threat of discipline increase a person’s awareness of risks or at least increase one’s interest in assessing the risks? Does this heightened awareness outweigh the learning through punishment?
  • By providing safety information and knowledge, are people more interested in assessing the risks? Does this heightened awareness outweigh the learning through punishment?
  • How does your system treat human error? Does your system make an employee aware of their mistake? Can an employee safely come forward if they make a mistake, so that your organization can learn from the event?

Positions for and against punishment as a means of learning are illustrated below:

In favor of punishment of the negligent actor: “when people have knowledge that conviction and sentence (and punishment) may follow conduct that inadvertently creates improper risk, they are supplied with an additional motive to take care before acting, to use their facilities and draw on their experience in gauging the potentialities of contemplated conduct. To some extent, at least, this motive may promote awareness and thus be effective as a measure of control.” (American Law Institute Model Penal Code, Article 2. General Principles of Liability, Explanatory Note 2.02, 1962).

Against punishment of the negligent actor: “a person acts “recklessly” with respect to a result if s/he consciously disregards a substantial risk and acts only “negligently” if s/he is unaware of a substantial risk s/he should have perceived. The narrow distinction lies in the actor’s awareness of risk. The person acting negligently is unaware of harmful consequences and therefore is arguably neither blameworthy nor deterrable” (Robinson & Grall (1983) Element Analysis in Defining Criminal Liability: The Model Penal Code and Beyond. 35 Stan. L. Rev. 681, pp 695-96).

Learning from unsafe acts

A Just Culture supports learning from unsafe acts. The first goal of any manager is to improve safety and production. Any event related to safety, especially human or organizational errors, must be first considered as a valuable opportunity to improve operations through experience feedback and lessons learnt (IAEAa).

Failures and ‘incidents’ are considered by organizations with good safety cultures as lessons which can be used to avoid more serious events. There is thus a strong drive to ensure that all events which have the potential to be instructive are reported and investigated to discover the root causes, and that timely feedback is given on the findings and remedial actions, both to the work groups involved and to others in the organization or industry who might experience the same problem. This ‘horizontal’ communication is particularly important (IAEAb).

Organizations need to understand and acknowledge that people at the sharp end are not usually the instigators of accidents and incidents and that they are more likely to inherit bad situations that have been developing over a long period (Reason, 1997). In order that organizations learn from incidents, it is necessary to recognize that human error will never be eliminated; only moderated. In order to combat human errors we need to change the conditions under which humans work. The effectiveness of countermeasures depends on the willingness of individuals to report their errors, which requires an atmosphere of trust in which people are encouraged for providing essential safety-related information (Reason, 1997).

2.3 Four types of unsafe behaviors

Marx (2001) has identified four types of behavior that might result in unsafe acts. The issue that has been raised by Marx (2001) and others is that not all of these behaviors necessarily warrant disciplinary sanction.

  1. Human error – is when there is general agreement that the individual should have done other than what they did. In the course of that conduct where they inadvertently caused (or could have caused) an undesirable outcome, the individual is labeled as having committed an error.
  2. Negligent conduct – Negligence is conduct that falls below the standard required as normal in the community. Negligence, in its legal sense, arises both in the civil and criminal liability contexts. It applies to a person who fails to use the reasonable level of skill expected of a person engaged in that particular activity, whether by omitting to do something that a prudent and reasonable person would do in the circumstances or by doing something that no prudent or reasonable person would have done in the circumstances. To raise a question of negligence, there needs to be a duty of care on the person, and harm must be caused by the negligent action. In other words, where there is a duty to exercise care, reasonable care must be taken to avoid acts or omissions which can reasonably be foreseen to be likely to cause harm to persons or property. If, as a result of a failure to act in this reasonably skillful way, harm/injury/damage is caused to a person or property, the person whose action caused the harm is liable to pay damages to the person who is, or whose property is, harmed.
  3. Reckless conduct – (gross negligence) is more culpable than negligence. The definition of reckless conduct varies between countries, however the underlying message is that to be reckless, the risk has to be one that would have been obvious to a reasonable person. In both civil and criminal liability contexts it involves a person taking a conscious unjustified risk, knowing that there is a risk that harm would probably result from the conduct, and foreseeing the harm, he or she nevertheless took the risk. It differs from negligence (where negligence is the failure to recognize a risk that should have been recognized), while recklessness is a conscious disregard of an obvious risk.
  4. Intentional “willful” violations – when a person knew or foresaw the result of the action, but went ahead and did it anyway.

2.4 Defining the border of “unacceptable behavior”

The difficult task is to discriminate between the truly ‘bad behaviors’ and the vast majority of unsafe acts to which discipline is neither appropriate nor useful. It is necessary to agree on a set of principles for drawing this line:

Definition of Negligence: involved a harmful consequence that a ‘reasonable’ and ‘prudent’ person would have foreseen.

Definition of Recklessness: one who takes a deliberate and unjustifiable risk.

Reason (1997) believes that the line between “culpable” (or “unacceptable”) and “acceptable” behavior should be drawn after ‘substance abuse for recreational purposes’ and ‘malevolent damage.’

Malevolent damage Substance abuse for recreation UNACCEPTABLE BEHAVIOR Substance abuse with mitigation Negligent error “ACCEPTABLE BEHAVIOR” Unsafe acts BLAMELESS BEHAVIOR

The following figure (Figure 2) illustrates the borders between “acceptable” and “bad” behaviors, where statements in the safety policy can deal with human error (such as omission, slips etc), and where laws come into play when criminal offenses and gross negligence are concerned. Procedures and proactive management can support those situations that are less clear, at the borders.

Figure 2. Defining the borders of “bad behaviors” (From P. Stastny Sixth GAIN World Conference, Rome, 18-19 June, 2002)

2.5 Determining ‘culpability’ on an individual case basis

In order to decide whether a particular behavior is culpable enough to require disciplinary action, a policy is required to decide fairly on a case-by-case basis. Three types of disciplinary policy are described below (Marx, 2001). The third policy provides the basis for a Just Culture. Reason’s Culpability Decision-Tree follows, presenting a structured approach for determining culpability. This is followed by Hudson’s (2004) expanded Just Culture diagram, which integrates types of violations and their causes, and accountabilities at all levels of the organization.

  • Outcome-based Disciplinary Decision Making – focuses on the outcome (severity) of the event: the more severe the outcome, the more blameworthy the actor is perceived. This system is based on the notion that we can totally control the outcomes from our behavior. However, we can only control our intended behaviors to reduce our likelihood of making a mistake, but we cannot truly control when and where a human error will occur. Discipline may not deter those who did not intend to make a mistake (Marx, 2001).
  • Rule-based Disciplinary Decision Making – Most high-risk industries have outcome-based rules (e.g. separation minima) and behavior-based rules (e.g. work hour limitation). If either of these rules is violated, punishment does not necessarily follow, as for example, in circumstance where a large number of the rules do not fit the particular circumstances. Violations provide critical learning opportunities for improving safety – why, for example, certain violations become the norm.
  • Risk-based Disciplinary Decision Making – This method considers the intent of an employee with regard to an undesirable outcome. People who act recklessly, are thought to demonstrate greater intent (because they intend to take a significant and unjustifiable risk) than those who demonstrate negligent conduct. Therefore, when an employee should have known, but was unaware, of the risk s/he was taking, s/he was negligent but not culpably so, and is therefore would not be punished in a Just Culture environment.

Reason’s Culpability Decision-TreeFigure 3 displays a decision tree for helping to decide on the culpability of an unsafe act. The assumption is that the actions under scrutiny have contributed to an accident or to a serious incident. There are likely to be a number of different unsafe acts that contributed to the accident or incident, and Reason (1997) believes that the decision tree should be applied separately to each of them. The concern is with individual unsafe acts committed by either a single person or by different people at various points of the event sequence. The five stages include:

  1. Intended act: The first question in the decision-tree relates to intention, and if both actions and consequences were intended, then it is possibly criminal behavior which is likely to be dealt with outside of the company (such as sabotage or malevolent damage).

  2. Under the influence of alcohol or drugs known to impair performance at the time that the error was committed. A distinction is made between substance abuse with and without ‘reasonable purpose (or mitigation), which although is still reprehensible, is not as blameworthy as taking drugs for recreational purposes.

  3. Deliberate violation of the rules and did the system promote the violation or discourage the violation; had the behavior become automatic or part of the ‘local working practices.’

  4. Substitution test: could a different person (well motivated, equally competent, and comparably qualified) have made the same error under similar circumstances (determined by their peers). If “yes” the person who made the error is probably blameless, if “no”, were there system-induced reasons (such as insufficient training, selection, experience)? If not, then negligent behavior should be considered.

  5. Repetitive errors: The final question asks whether the person has committed unsafe acts in the past. This does not necessarily presume culpability, but it may imply that additional training or counseling is required.

Reason’s Foresight test: provides a prior test to the substitution test described above, in which culpability is thought to be dependent upon the kind of behavior the person was engaged in at the time (Reason and Hobbs, 2001).

The type of question that is asked in this test is:

— Did the individual knowingly engage in behavior that an average operator would recognize as being likely to increase the probability of making a safety-critical error?

If the answer is ‘yes’ to this question in any of the following situations, the person may be culpable. However, in any of these situations, there may be other reasons for the behavior, and thus it would be necessary to apply the substitution test.

  • Performing the job under the influence of a drug or substance known to impair performance.
  • Clowning around whilst on the job.
  • Becoming excessively fatigued as a consequence of working a double shift.
  • Using equipment known to be sub-standard or inappropriate.

Hudson’s Version of the Just Culture Diagram (Figure 4)

Hudson (2004) expands Reason’s Culpability Decision tree, using a more complex picture that integrates different types of violation and their causes. This model starts from the positive, indicating that the focus of priority. It defines accountabilities at all levels and provides explicit coaching definitions for failures to manage violations. This approach (called “Hearts and Minds”) includes the following four types of information to guide those involved in deciding accountability:

  • Violation type - normal compliance to exceptional violation
  • Roles of those involved - managers to workers
  • Individuals -the reasons for non-compliance
  • Solutions - from praise to punishment

Figure 3. From Reason (1997) A decision tree for determining the culpability of unsafe acts. p209
(click for larger image)

Figure 4. Hudson’s refined Just Culture Model (From the Shell “Hearts and Minds ” Project, 2004) (click for larger image)

Determining Negligence: an example (SRU, 2003)

  • Was the employee aware of what he or she has done? NO
  • Should he have been aware? YES
  • Applying the “Substitution Test”: Substitute the individual concerned with the incident with someone else coming from the same area of work and having comparable experience and qualifications. Ask the “substituted” individual: “In the light of how events unfolded and were perceived by those involved in real time, would you have behaved any differently?” If the answer is “probably not”, then apportioning blame has no material role to play.
  • Given the circumstances that prevailed at the time, could you be sure that you would not have committed the same or similar type of unsafe act? If the answer again is “probably not”, the blame is inappropriate.

Dealing with repetitive errors

Can organizations afford someone who makes repeated errors while on the job? The answer to this question is difficult as the causes of repeat errors have two different sources:

1) An individual may be performing a specific task that is very prone to error. Just as we can design systems to minimize human error through human factors, we can design systems that directly result in a pronounced rate of error. Therefore it is critical for the designers to be aware of the rate of error.

2) A source of repeated error may be with the individual. Recent traumatic events in one’s life or a significant distraction in life can cause some individuals to lose focus on the details of their work, possibly leading to an increased rate of error. In such cases, it may be an appropriate remedy to remove the individual from his current task or to supplement the task to aid in controlling the abnormal rate of error.

What to do with lack of qualification?

An unqualified employee can cross the threshold of recklessness if he does not recognize himself as unqualified or as taking a substantial risk in continuing his current work. Lack of qualification may only reveal that an individual was not fully trained and qualified in the job and therefore show that it is a system failure not to have ensured that the appropriate qualifications were obtained.

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Reprinted by permission from the Global Aviation Information Network.


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