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Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me Dr Tony Power. He’s founder and Principal Consultant at Just Culture Consulting. He’s a leading expert in the world around just culture and the implementations with quite the diverse background, which we’re going to get into very soon, from legal to aviation to teaching a lot about and safety culture. Tony, welcome to the show. Very excited to have you with me.

Thanks, Eric, for inviting me. I’ve been really looking forward to this.

Absolutely. Let’s get started with your diverse background and what got you so passionate about safety.

Yeah, it’s been a bit of a journey. I suppose growing up, I had a couple of passions. Initially, one was law. I grew up watching some legal dramas, and the other was aviation, was flying. I ended up starting my career as lawyer. One of the big drivers for me was that sense of justice and fairness. I always hated it when I saw people being treated in an unfair way. That was a big driver for me. Then when I got into law, I was working as a young solicitor for a city law firm here in Australia. I saw the way that safety was often dealt with by the law and sometimes the way that frontline people were effectively made responsible for system failures That really tended to trouble me, but I didn’t really have a good handle on exactly why. Then a few years later, while I was still relatively young, before I got a mortgage and all those sorts of things, I said, oh, I’ll make the career change to my other passion, which is aviation. And as I went back to study and got my pilot’s license and did an aviation degree, and that’s where I came across safety management and in particular, just culture.

And that really spoke to me, this idea that, well, if you treat people in a just and fair way, that is not just a good thing in and of itself, which it certainly is, but also that it brings a whole lot of safety benefits as well. So that then led me to really diving into that and ultimately pursuing a PhD, teaching at university on safety culture, just culture, safety management, and then ultimately then from that to founding Just Culture Consulting and really focusing in on that just culture implementation and helping organizations to be a more just and fair place to work, which I think is something that everyone deserves to have, whether you’re a receptionist or a mechanic or a supervisor or a CEO.

It has to feel fair. Let’s start with this element of just culture because a lot of people talk about it. Can you share maybe a little bit about what is it and maybe some elements of what it’s not? Because it’s sometimes in some circles has an incorrect connotation, I would say.

Yeah, absolutely. I think safety culture really came out of a response to two other alternative cultures, one being the blame or the punitive culture and this idea that, well, when things go wrong, it’s a result of bad choices by bad people. If we get rid of the bad people or we punish them, then our systems will be safer because people will be deterred from making errors or the ones who are prone to be error prone. But the problem that we found with that was that that meant that people, if they made a mistake or error or something, they wouldn’t say anything because they’d be worried about getting punished. So, the safety information sources dried up and It’s been long recognized. It’s not a great way to run an organization, both the general environment that it creates and also the negative safety impacts. Then there’s a response that there was this shift to a no-blame culture and this idea that, well, as long as you report you’ll be immune from blame or from punishment. This idea that any use of blame or even possibly accountability when things go wrong is detrimental to safety. Sure. That certainly is a good movement away from a blame culture.

But it can lead to this idea that accidents are always the result of interactions in complex systems and that there’s no individual agency. You can come to see accidents as acts of God if you like, rather than preventable occurrences. There’s been some research in the US with construction about these attitudes being driven by purely no-blame cultures.

Environment, yeah.

Yeah. A just culture is attempted to find a middle ground between those two, where we encourage safety reporting through a non-punitive response to human error. We understand that people generally intend to go to work, intending to do a good job, but humans are fallible, and they will make errors from time to time, even when they’re trying their best. It’d be unjust to punish them for those. But we retain standards of accountability, that line between acceptable and unacceptable behavior. Things like, for example, deliberate harm or grossly reckless conduct, which is uncommon but still needs to be dealt. It needs to be addressed. An organization that, for example, doesn’t properly address things like deliberate harm is one where the other the other work is not going to feel safe or not feel that safety is being taken seriously. It’s really about anchoring accountability into the science of how humans work in systems, not blaming people for errors and mistakes that have been induced by the system, but still retaining that space for individual accountability assessment of quality of people’s choices they make within the constraints of that system. Yeah.

I think the notion you talk about in terms of accountability as well is an important one because I’ve often heard, obviously, no blame people saying there’s an absence of accountability. But there’s some people also question whether there is accountability in a just culture environment. Can you touch a little bit about what accountability should look like, and maybe even redefining what that word is? Because sometimes when you ask people what accountability is, they automatically assume accountability as I beat you into submission to do what I told you to do or accountability as I terminated you. That’s really not the definition of accountability.

Yeah, 100%. I think there’s that conception that just culture has an absence of accountability. I think that often that arises because we might have a very narrow definition of what accountability is. That, as you say, is that we’re going to hold someone accountable, and so that means we punish them if something goes wrong. But I think accountability in just culture, I think just culture broadens accountability a lot more widely, both on the individual level, but also it extends accountability to the organization. The individuals in the system are accountable for the quality of the decisions and choices and the actions that they take, but the organization is accountable for the systems of work that it creates and operates. It extends that accountability. When we’re talking about accountability itself, often we can default that accountability equals blame. I think that’s not necessarily the case. When we’re talking about blame, I think there’s two elements that we can distinguish between blame and accountability. The first is with blame, there’s a sense of causation. Well, the bad thing happened because was you did X. Sure. Then the second is a sense of moral condemnation that, well, you shouldn’t have done X, or you should have done Y.

Part of the problem with that is it tends for us, one, it can be unjust because we’re not considering the wider context, but we’re also limiting learning. We’ve already decided what the cause is, and that leads us towards a penalty. Then that then leads to errors mistakes being hidden, as we’ve touched on before. But I think accountability is a concept that can and should be much wider than that. Firstly, we can distinguish between backwards accountability and forwards accountability. Backwards accountability, we’re talking about looking backwards in time and how can we treat people fairly based on the quality of their actions and decisions. There it’s really around, again, as I mentioned before, anchoring that in the science of human factors, how people work in systems, understanding that full context, asking, why did this make sense at the time? It may well be that a person can make a mistake without it necessarily being a moral failing in the sense of blame. Or that they are the sole cause of something that has gone wrong. And so, in just culture, accountability becomes more about ownership and responsibility. Responsibility, not in a causative sense, but in a sense of duty and obligation.

So, it might be an obligation to explain and justify actions. It also, in a just culture, balances that backwards accountability with forward accountability. And so that There’s this idea of, well, who’s got the duty to make things right regardless of who or what or might have been at fault or cause of the something going wrong. A person can be accountable and take responsibility for things that go wrong without meaning that they’ve morally failed in some way. To bring that back to the individual and the organization, the organization can hold itself accountable for by understanding what has gone wrong and committing to improve their systems in the future to make it less likely that something like that is going to happen in the future. That’s them taking accountability in a forward sense. Then for the individual, that accountability might take the form of giving their account of explaining what happened and the circumstances in the context. They’re taking that obligation of that explanation and what they are potentially going to do in the future to do things differently in the future to improve performance, whatever that might be. I don’t think just culture is that get-out-of-jail free card.

I think it takes accountability very seriously, but it makes sure that it’s done in a fair way by anchoring it in human performance, human factors, and it’s holding organizations accountable. So, there’s mutual accountability for the systems of work they design and create and looking at that full context in which people work.

But isn’t the element of accountability even broader. So, beyond what you characterize as, I’m holding you accountable, which is, I think, the colloquial expression to potentially even accountability could even be retraining in a particular set of circumstances. So maybe in a certain set of circumstance, I’m more likely to fail. Maybe I need to go retraining, or maybe we have a system challenge where the training hasn’t necessarily hit the mark on a particular skill set or a particular scenario.

Yeah, 100%. That’s a really good point. Probably should have made a bit clearer because that’s 100% right, that often we equate accountability with sanction or punishment. Accountability does not have to include those things, and probably more often than not should not include those things. There are certain circumstances were potentially, yes. But as a general rule, particularly if you’re looking at something that’s occurred and you’re seeing those system influences. For example, it’s a training issue. Well, there’s two levels of accountability there. One is that the person involved might need some retraining, as you mentioned. But then so that’s accountability for the individual. But then for the organization, were there any issues with the training system that led to that? What accountability are we going to take to make improvements to our training or our selection process or whatever it might be to reduce the chance of getting into whatever that situation was? Admittedly, it can sometimes be difficult for organizations, even when they’re trying not to be punitive in their responses, when it comes to things like retraining or coaching and things like that, to avoid punitive effects. Because someone’s, let’s say, a pilot has been taken off the line because they’re doing some more simulated what they’re retraining, that might mean that they are not receiving the normal financial allowances, working away from home allowances, meal allowances, things that they might normally be receiving.

I think it’s really important for organizations to when they are looking at responding to events and they’re trying to be non-punitive, which I think they should be, is to really look wider than just are we formally punishing them? But look at the wider effects and try to mitigate any inadvertent punitive impacts. Because sometimes things can feel punitive even if they’re not. And that’s about, Jim’s got to go away and do training, and that can cause embarrassment amongst his peers and things like that. And so, trying to create a culture where, for I suppose things like training are normalized and something that everybody does from time to time to reduce that social stigma is a really important thing about, again, trying to reduce those unintended punitive effects. Sure.

As people are exploring just culture, there’s a few models out there, one that’s more commonly referred to, the Jim Susan’s model. Can you share maybe a little bit about what are some of the models and what’s worked, maybe what hasn’t worked?

As you say, a lot of people will be familiar with that classic version of just culture developed by James Reeson and David Marx. It’s sometimes called a retributive just culture, which is one of those things where it’s technically a correct term, but it’s a bit misleading in that it’s not supposed to be about retribution. The idea is that through just responses to human error, you’ll generate a report in culture. You’re trying to treat people in a just and fair way and not blame the individual for errors that have been induced by the system of work. But it’s very much focused on what happened, how did this person deviate from the norm, and then what’s a just way to respond. It has some strengths to it in that many people have seen that James Culture Capability diagram. You can get some consistency through those standard templates, and that’s that strong emphasis on fairness. But it does have some weaknesses. There’s less emphasis on the other stakeholders involved. It’s very much focused on the frontline person. Unless you are very active about running that just culture model, not just with the frontline person, but with others such as supervisors or managers, they tend to get missed.

The other thing, part of that framework is it tends to go to the individual factors first. Was it deliberate? Was the person affected by an illicit substance or something like that? You exhaust all the individual factors first before you get to the system factors. Sometimes what that means is you never actually get to those system factors. What that can often lead to is in the just culture being a vehicle for individual focus on individual accountability, individual punishment. And so, you get this sense of, I got just cultured, or we need to just culture this person. So, there’s been instances of that poor implementation, poor reputation as a result. Sure. As a result of So as a result of some of these weaknesses of that classic model, there’s been a movement in more recent times for a restorative just culture, and that’s something that’s been developed primarily by Sydney Decker. And that draws from restorative justice concepts It’s developed in the 1970s and even earlier, but it’s really focused on restoring trust and relationships after an incident of harm or injustice. And so, it has some different guiding questions. It’s asking, who is hurt? What do they need?

Whose obligation is it to address each need? It’s really strong on redefining the accountability from rather than an account that you settle, that backwards-looking to a story that you tell, forwards-looking. So, accountability comes from giving your account of what happened. And one of the big strengths of this model is that it includes a much wider range of stakeholders. Because let’s say you have a situation where a worker has made an error and, say, a customer has been injured by it. So, asking who is hurt. Well, immediately you’ve got the customer who’s been, say, physically injured. You You’ve got the worker who’s made the error. They have been hurt. They might be feeling shame, worry about losing their job, feeling regret. So, they’ve been hurt. The organization has been hurt because they may have suffered reputational damage. Sure. By its nature, it draws in more multiple stakeholders involved. Then ask, what do they need and whose obligation is it to address each need? The person who’s been injured, well, maybe they need to understand what happened. They might need support. What from the organization, medical bills and things like that. The person who the worker who perhaps made the mistake, well, they might need reassurance from the organization about perhaps their job security and things like that.

The organization has needs, and it’s to understand what happened so that it can put in place measures to prevent reoccurrence, looking at those systematic changes that it can make. Each of those needs has been obligations from various parties. It draws in a much wider range of narratives and has that real emphasis on restoring trust and relationships. You have a much less chance of a punitive response coming out of that because you’re looking at what do we need to do moving forward to address the needs that everybody has. It certainly, I think, is a great improvement on the classic model. It does have some weaknesses. The first is that it’s a restorative model, so it assumes that there’s been some harm or damage. It doesn’t really leave much room for, for example, recognizing exceptional performance or that normal work. It’s focused on restoring things when things get broken. The other thing is that it can sometimes still require judgment of competing narratives. Someone says that an action was it was deliberate. Someone says it was accidental. Well, those narratives might be irreconcilable, and there might be circumstances when if you are… What is going to be restore things is going to require some judgment on of what actually happened, at least as far as you can get.

It can sometimes struggle with those extremes of behaviors which are rare but do happen, such as deliberate harm. Well, we’re going to restore you by exiting you from the organization. There can be a There could be a bit of a tension there between what you’re saying about restoration, but what ultimately you might need to do to protect the organization and protect the public, which are rare circumstances, but still sometimes happen. The other thing is the implementation can sometimes be complex and resource intensive. You need people who are well-versed in restorative practices to be able to… You need a lot of organizational capacity to do that. The final model I’ll just mention just quickly is a revised or hybrid model. This has been developed by people like Paul Stretton and Mazin Nazarouk and people like that. It’s really trying to take the best elements from both the classic and the restorative approaches and balance learning and restoration and fair accountability and bring in some of those aspects of safety, too, around learning across the full spectrum of human performance, of bringing in that local rationality of why things made sense to people at the time. Some of guiding questions around what happened, why people’s actions make sense to them at the time, what can the organization learn from what happened?

They tend to retain the individual focus from the classic models. Again, you’d have to run multiple times to capture all the stakeholders. But it starts with the contextual factors, the why did it make sense at the time. You exhaust all those system and contextual factors, and you only really get to the individual account accountability factors if it’s necessary, if you get there. So again, you’re less likely to get to a punitive place, and you’re more likely to generate understanding and organizational learning. Again, it’s got some weaknesses. Again, the implementation can be complex. It can depend a lot on how well you learn as an organization. And achieving that right balance between learning and restoration and accountability is a challenging one.

It can be quite challenging.

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We’ll get to how you could get started. But first, I think you have a background in law. The legal environment can get in the way. Regulatory environment can also get in the way of just culture. When the FA introduced early elements around near misreporting, as an example, there was still risk of punishment for almost a decade that came from different jurisdictions. That impeded, obviously, learning when you think you could end up in jail. That’s usually not. It doesn’t feel safe. This is a long, long time ago, of course. What are some of the things that could compromise from a regulatory standpoint? Maybe how can an organization deal with it? Because there’s a lot of regulated industries.

The surrounding regulatory framework will potentially have a big impact on what you can do as an organization when it comes to just culture. It sounds there’ll be legal requirements around mandatory reporting of certain incidents. Then once the organization reports that to whatever that is, to a regulator, well, then they don’t have control over what the regulator may or may not do with that information. There’s also the concern about legal liability. In particular, for example, criminal liability for work health and safety breaches. That is both for workers themselves, for managers, and for the organization as an entity. The consequences of criminal prosecution in those instances, they’re serious. It’s something that organizations do have to take seriously. But what that can mean is if you have a serious incident is that the lawyers come in, they say, Right, we need be very careful around what information we gather, what information we disclose, because anything that we do is potentially going to land on the prosecutor’s desk, and we’re going to be potentially making their case for them. But of course, that runs completely counter to what we would normally want to do with a just culture, which is to understand what happened and to learn and distribute that learning.

So, it can often be a difficult compromise between what we want to do as an organization and some of these other considerations. Insurers as well can sometimes place barriers into things like reporting schemes because they’re, again, worried about legal liability. I think there are some things that… That’s the reality that organizations have to face. I think one of the most important things, therefore, for organizations to do is not to make promises to their workers that they can’t keep and being up front with their staff about how things will go under certain circumstances. To say, look, if we have a serious incident, legal liability for the organization and for you as individual workers may be a factor that we have to consider, and that means that we might have to do things differently. But rather than it being a surprise, people go, hang on, what happened to the just culture process? That it’s something that’s been talked about up front. But certainly, even within that, we can still, I think, apply our principles that as an organization, we are not going to punish people for making mistakes when they’ve come to work to try and do their best and things have gone wrong.

So even if we can’t, but we might have to be upfront that we’re not going to be doing that, but that we can’t necessarily stand in the way of regulators and others taking action. The other thing is to engage in dialog as an organization with the lawyers and insurers and to talk about that long term gain as a short-term gain. We might protect ourselves in the short term from liability but are we setting ourselves up for difficulty in the long term because we’re not properly addressing safety issues, because we’re not learning as an organization. Learning, correct. Sometimes there can be an excessive amount of caution or fear around this stuff. Yes, it’s something to be taken seriously, but that doesn’t mean that we have to go with a blanket rule of just, Right, we’re going to batten down the hatches and stop everything. It might be that in a certain circumstance, well, a prosecutor has everything that they need already, so we’re not actually exposing ourselves to any greater risk by being open. Sure. Of course, think about the other considerations as well around that there are benefits towards that forward’s accountability of being open and transparent and showing as an organization that you are committed to systematic improvement and to learning and treating people fairly.

That can be helpful in the legal sphere. It shows courts that you take safety seriously, but also in the court of public opinion and what your customers feel about you and your reputation as a good corporate citizen. The public tends to not look too kindly on organizations that do batten down the hatches and deny, deny, deny. So, I think looking at weighing up the various considerations, not just going from a point of view of, well, the best legal option is X, therefore we must do it. Having that discussion and looking for that nuance. And there are more technical things being on your jurisdiction around commissioning incident reports through the lawyers to get legal professional privilege and things like that. They’re not ideal, but it might be the only option that you’ve got in that circumstance. There are ways you can address those situations. But ultimately, what I would say is that organizations It’d be really good if they advocate for more legal reform in the aviation space. When we have an ETSB in the US or ATSB investigations in Australia in aviation, we have this We have this whole framework around incident reports, which are not about assigning liability, but are about learning.

I think advocating for giving organizations more ability to be open and transparent in order to facilitate that learning, but with some protections in place. This stuff is not used for legal liability. It’s something that I think is well worth advancing.

I think in the context where the bigger concern is the regulatory body, there’s a lot that can be done as an industry to get the regulatory body there, potentially find ways to improve. Definitely, you talked about the ETSB, the TSBR and TSB all have had very similar practices in terms of learning. You’re starting to see permutations in other sectors that are also regulated. The one that’s a bit more challenging is when it’s outside litigation because they don’t necessarily care about the long term. They’re seeking remediation for an event.

Yeah, that’s right. But I think that’s going to be one of those considerations to weigh up as well. There’s been experience, for example, in health care, where hospitals have been open and transparent with patients when things have gone wrong. The chance of that patient or their family initiating litigation reduces significantly It doesn’t eliminate that risk, but it makes it much less likely. And so similarly, I think that’s something that we can take to other industries and there may be more opportunities to have a just culture, to be more open and transparent, and that in itself might head off legal risk rather than a blame or batten down the hatches type approach, which may actually guarantee a lawsuit.

Litigation, correct. Yes. A lot depends on jurisdictions and how much is at stake and all sorts of different elements. But absolutely, the healthcare is a very good example. Even how the doctor responds to an event in terms of acknowledging responsibility or acknowledging what could have been different has been demonstrated to greatly diminish risk of litigation.

Yeah. That’s where that restorative process can really work really well because you bring in more stakeholders, including, for example, in the healthcare space, a patient or their family into that process. That can be incredibly powerful and healing for everyone involved.

That’s what we’re involved. Lastly, we touched a little bit on models. We talked about legal framework. If somebody’s interested in starting to contemplate, how do I move forward around just culture? How does one get started? The models can be a lot to even wrap your head around.

Yeah, I think the first thing to recognize is that just culture is not just putting words onto a policy document. It’s a journey, I would say, of building mutual trust through consistent behavior. I would strongly suggest that a just culture implementation is not dictated by a flowchart or checklist. You just whack that in. But it’s about the values and purposes of a just culture approach as being the guiding star to implementation. Sure. Embedding those values of justice, of fairness, of transparency. That’s going to look different for different organizations. Really, one of the first steps, I would say, is to form a steering group that’s going to lead that planning and implementation and to get that senior management commitment, that senior management, senior leadership that they commit, that they believe in the concept of a just culture and the benefits it will bring to the organization and the people in it. They’ll extend some trust that staff will speak up and that they’ll allocate the time and the resources to implement a just culture. It really does start at the top and that commitment and then that consistent behavior and then that will then flow across and down the organization.

The other thing I would say is it’s really important to involve all stakeholders into that design process so that it’s not just a safety thing, because that can be one of the pitfalls sometimes is a safety is doing the just culture thing over here, and HR or legal operations are doing something completely different somewhere else. And that’s much more likely to be successful in obtaining the safety benefits of just culture, but also the wider organizational benefits of a just culture in terms of increased employee engagement, reduced employee turnover, better performing systems of work because it’s something that is embedded across the entire organization rather than just in the safety department. Sure.

Makes sense.

Then finally, I’ll also just say that you want to understand where you’re currently at. Do a bit of a gap analysis, understand what your current culture is like. Because, for example, there might be existing hurts that are there or historical hertz that you might need to address so that you can then reestablish trust to then move forward. Sure. But really, it’s start at the top and work down.

And work down. But also, like your point about going beyond safety, because if HR is taking a very aggressive path to terminations in other contexts, it can bleed over. Your comment around even historical, you call it historical hurts, is very real. In some cases, there are urban legends that maybe nobody in the organization experience, but they heard as they onboard in terms of what can happen and how somebody treated somebody else. All of that is embedded in the DNA of the organization.

Because an organization that’s beginning a just culture implementation, it’s not starting from zero. It has a whole history and a context. They say that it might have those urban legends, those ghosts that are still haunting. It’s like, oh, you heard what happened to Fred? When he reported something and look what they did to him.

Seven years before I was born. That’s right. Yeah. And so, Tony, if somebody wants to get in touch with you to explore how they could go about implementing Just Culture, what’s the best way for them to do that?

Yeah, there’s a couple of ways. I’m always very much happy to have a chat around Just Culture issues. It’s the thing that I’m passionate about, as you can probably tell. So, one way is through my website, https://www.justculture.com.au/. You can make an appointment on there or email me. Question happy to answer those. I’m also fairly active on LinkedIn. So, if you look up Tony Power, Just Culture on LinkedIn, I’ll come up and I post it on there. Feel free to message me on there as well.

Excellent. Well, thank you so much for joining me today. Really appreciate the conversation around just culture and really what does accountability look like in this context and approaches models that worked and the connection between the legal frameworks that are around and even the regulatory side and how we can help overcome. Ultimately, the main goal of this is to learn before something significant happens.

Yeah, exactly. That’s 100 %. It’s really about trying to get that safety data and be proactive. Yeah, rather. But yeah, thank you very much for having me on. It’s been an absolute pleasure. I’ve really enjoyed this discussion.

Excellent. Thank you so much.

Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at execsafetycoach.com. Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.