This is an excellent book for anyone with an interest in safety, organisational learning or even justice and philosophy. Dekker’s book explores the tension between enabling an environment that encourages people to come forward with safety concerns and maintaining a degree of accountability so that wilful negligence is punished. Media demands that “something must be done” following major accidents all too often seek to punish people that were simply doing their job to the best of their abilities. Dekker shows how hindsight can be very unhelpful, especially when wielded by a zealous journalist, ambitious prosecutor or even an apathetic juror.
Through examples from healthcare, civil aviation and defence, Dekker demonstrates what happens after charging employees with murder, manslaughter, gross negligence when, if a ‘just culture’ had prevailed, the accidents or incidents in question might have been viewed as learning opportunities rather than crimes. Unintended consequences include colleagues clamming up, with no-one willing to admit to mistakes and work practices becoming increasingly defensive, occasionally increasing the risk to patients, passengers and the general public.
Dekker argues that the absence of a just culture damages morale and people’s commitment to their colleagues and employer; job satisfaction is reduced, as is the likelihood that people will step outside their formal roles, thereby reducing the flexibility that so many organisations need. Finally, the lack of a just culture causes (and is partially caused by) an erosion of trust between people that should see one another as colleagues.
This book contains ideas that make uncomfortable reading for those of us that like to believe in personal responsibility; it also makes clear that there is no such thing as an objective truth. There are only multiple perspectives, the combination of which is the best way to arrive at an account of ‘what happened’ that is as fair and accurate as possible.
Finally, Dekker explores the concept of blame and suggests that we blame one another for actions that are errors because of an unwillingness to admit to a lack of control. The modern world is complicated, fast-paced, inter-connected and prone to unpredictable events. Conceding, as individuals and organisations, that we actually have far less control than we claim, is too frightening for most of us, hence this fiction that all accidents can be prevented.
Strong stuff.
I don’t necessarily agree with all of these arguments but I recommend anyone with even a passing interest in these ideas to read this book.
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