A fundamental tenet in Just Culture is that all humans are
fallible. Perfection is a noble goal,
but it is unattainable. We will make
mistakes. We will slip. We will have lapses. We will drift into a false state of security and
take risks we believe to be justifiable.
It is part of being human.
Another fundamental precept in Just Culture is duty. All people have a duty to each other to cause
no unjustifiable risk or harm to another person…this is the higher order duty,
one given to us by God. Causing harm
would be conduct that endangers the things we protect: life, liberty or autonomy, and property
(something we can lose, i.e., family, house, reputation, etc.)
There are two other subordinate duties that we subscribe
to: Duty of Procedural Rules (work
policies and procedures), and the Duty of an Outcome (getting to work on time).
In the United States there are 3 values we hold dear per our
Constitution: life, liberty and the
pursuit of happiness. Life is provided
by God, and/or our Creator. Liberty is
the opportunity to exercise free will. The
pursuit of happiness is the driver of behaviour for most of us.
Doing what makes us happy can create pure joy if acquired
without harm others. The reality is that
as we selfishly go about pursuing happiness, we often engage in risky or
reckless behaviours to get there. Let’s
look at something as simple as exceeding the speed limit. We can reasonably assume that people are
happier if they get to a determined destination sooner than later. Over the past year, on a 35 mile stretch of
interstate, I have arrived at the scene of 6 over-turned vehicles 2 to 10
minutes after the actual event. All were
single car events travelling over the speed limit. Half of those accidents had
fatalities. I saw a body in the median
of one accident before EMS arrived. This
individual was thrown from his truck and my car was the third or fourth one to
pass by the accident after a couple of cars had stopped before my arrival to
provide aid.
Almost all drivers exceed the speed limit from time to time. Some people go beyond the speed limit without
being aware and self-correct once they realize they are there. My sports car is one that requires vigilance
to watch the speedometer. In a Just Culture,
this infraction is considered a human error.
Others will intentionally exceed the speed limit, but stay in the
socially “safe” zone of no more than 10 miles per hour over. These folks
consider it safe, because they have never had an accident and they know that
most police will not enforce the speed limit until it gets beyond 10 mph of the
speed limit. This infraction is
considered at-risk behaviour. Anybody who goes over the speed limit by more than 10
mph could be considered as engaging in reckless behaviour. Obviously, the faster we go, the more risk we
pile on in extending harm to self and others.
It could be argued, that anyone going 1 mile over the speed limit could
be reckless behaviour with the argument being; what makes us more qualified to
judge what is the maximum safe speed that the engineers who built the
road? Society and cultures generally
determine which conduct falls into any of these categories. On an individual basis, it is the silent personal
voice that tells you what you are doing is wrong and negligent, yet you do it
anyway…reckless.
Historically, in the legal system, we look at the outcome
when there is an accident. Let’s say we
have two people who both are driving under the influence. They know it is wrong. There is no intent to harm. It is a gamble. One person gets pulled over by the police and
is fined for this crime, but does no jail time.
The other person has an automobile accident and kills a person in the
car his/her vehicle hit. It can assumed that this person will be
incarcerated and the time in jail depends on which state the event
occurred. The conduct is the same for
both people, yet we have different penalties.
Justice or not? When we gamble, luck
(being at the wrong place at the wrong time) determines the extent of punishment. The legal system is flawed
because people created it, and people are fallible.
In a Just Culture we do not factor in the outcome of the
event. We search for the cause of the
accident and examine the behaviours / conduct of the people involved in the
event. Most often, investigations lead
to system breakdowns that either generated or supported the error(s). If it was a human error, then we console that
person. If it was at-risk behaviour we
counsel that person and give them alternative behaviours to employ in the
future. Reckless behaviour incurs
disciplinary action.
Life, as we know it, is finite. For every birth there is a complementary
death. Life is a social value. Social populations create imposers to
establish laws, rules and regulations to protect life. For example, in the 1960’s and 1970’s lap seat
belts were optional accessories in cars.
It was found that there was a 30 – 50% higher rate of fatalities in
accidents of people who did not wear seat belts. As a result, New York, in an attempt to save
lives, was the first state to create a rule that required the wearing of seat
belts mandatory in 1984. To protect life, we have to give up some
liberty. This does not suggest
we move to socialistic form of government, but sometimes we have to protect
ourselves from ourselves.
In our society there has always been a challenge to balance
free will / liberty and people’s pursuit of happiness. History has shown that we continuously
change as events of the day raise social awareness to the point that the collective
society demands Imposers to create social order.
The events of 9/11/2001 required us to think differently
about immigration, travel, terrorism, and protection of life and liberty. No longer
can we say our farewells at the gate in the airport, unless it is a minor flying
unaccompanied, and we subject ourselves to possible personal searches as we
make our way to the gate. Is it inconvenient? Absolutely!
Does the security checks impede on my pursuit of happiness? Of course it does! Is it a necessary evil that helps to assure
society that air travel is “safe?” Yes!
There is plenty of controversy around the proposed gun
restrictions. The current prevailing argument
is around the infringement of the 2nd Amendment of the
Constitution: the Right to Keep and Bear
Arms. It is freedom and liberty many people highly value. Recent mass casualties from firearms designed
to dispense a large number of ammo in a rapid fire delivery have suggested that
we need to have an imposer create laws, rules and regulations to protect life,
which subscribes to the higher duty. In
the end, the collective social conscious will eventually dictate the outcome,
whatever is it, whether we agree with it or not as an individual. That is the democratic way.
As we navigate into the future, we will have imposers for
our collective and personal benefit, but as free Americans we will also have
the freedom to do what many in the world cannot. A Just Culture can change an organization to
be more tolerant of mistakes people make that are not a result of reckless conduct
and design more effective systems to afford people to make safer behavioural
choices and reduce likelihood of errors.
A Just world can exist if we collectively adhere to the highest order
duty – cause no unjustifiable harm or risk to others. With 7 billion people and varying personal and
cultural agendas, this task is easier said than done, but not impossible. And so, the mission begins, one person at a
time for the sake of a just world.
