The Just Culture Foundation

1
The Just Culture Foundation
Job Brüggen June 19th, 2007
2
What is the most common aspect for the following
sectors
Aviation
Medicare
Shipping
Nuclear / Process Industry
Rail
Their job is one of societys charities
They are highly educated and well trained
A
C
Human Error can result in high profile accidents
They work shifts and are prone to tiredness
B
D
3
Something went wrong, so somebody must have done
something wrong?
door
you
4
Borders of tolerabilityImmunity is NOT advisable
Gross Negligence
Slips Lapses
Criminal Offenses
Omissions
Mistakes
Violations
Law enforcement
Law enforcement
Safety Management
5
NO! Civilized societies require advanced
learning systems
Improve
Safety defenses
Analyze
event
Human error
Pre- conditions
Change
6
Our business is protecting people!

• Humans WILL make errors
• Criminalization of human error is
• intolerable
• Vital safety information WILL be withheld
• Safety improvement IS impaired
• Further lives WILL be lost

7
We must ACT !
collectively

• So we lock up one or two. Who cares?
• No dossier alone is strong enough to win them
  over
• E.g. aviation is already much too safe
• More professional interest groups must be reached
• Just Culture forces must be globally UNITED and
  STRENGTHENED

8
Social Dialogue at what level?
Sector
Government
General Public
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What could be a good plan?

• A dedicated organization or network
• To lay the foundation for change of societys
  climatefrom punitive to advanced learning.
• Global, multi-sector reach
• Long term outlook (10 years)
• The Just Culture Foundation

10
The Just Culture Foundation
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World Wide support. Think Big!
12
Where are you living?
Civil Servants?
Industry?
This audience?
Parliament Members?
Its done!
Politicians?
Innovators
Early Adopters
Early Majority
Late Majority
Laggards
Diffusion of innovations theory was formalized by
Everett Rogers in 1962. Adopters of any new
innovation or idea could be categorized as
innovators (2.5), early adopters (13.5), early
majority (34), late majority (34) and laggards
(16), based on a bell curve.