In today's episode, David and Drew examine the fundamental problems with just culture models through analysis of a BP case study from the Journal of Loss Prevention in the Process Industries titled "From Individual Behavior to System Weaknesses: the Redesign of the Just Culture Process in an International Energy Company." The discussion centers on how these frameworks, originally designed by Jim Reason to reduce individual blame, often become tools for discipline rather than system improvement, despite well-intentioned redesign efforts.
You'll hear about BP's attempt to create a fairer process using eight new questions that focus more on system factors like management influence, procedural clarity, and organizational goal conflicts. They discuss how even this thoughtfully redesigned framework still resulted in predominantly individual-focused interventions, with 80% of actions targeting people rather than systems, despite classifying most incidents as system-induced errors. The episode provides critical insights for safety professionals questioning whether just culture processes add value or represent organizational clutter that should be eliminated entirely.
Discussion Points:
Quotes:
David Provan: "I think the problem with the just culture model is that we have a just culture model."
Drew Rae: "If your system problem is, we are not leaning hard enough onto individuals to behave correctly, then you are not really doing system thinking."
David Provan: "Even though we are saying that, you know, this is great because 79% of these cases have now been classified as system-induced errors, over 80% of the actions as a result of those system-induced errors are at the individual leve.l"
Drew Rae: "Every single outcome from the process is some sort of statement about disciplining a person, even when it's not disciplining a person. That's still the focus."
David Provan: "Any process that you put in place in your organization that doesn't have these quality management aspects is likely to be something that drifts away from its intended purpose."
Resources:
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[00:00:00] David Provan - cohost: You are listening to the Safety of Work podcast, episode 130. Today we're asking the question, what are the problems with just culture models? Let's get started.
[00:00:24] David Provan - cohost: Hey everybody. My name's David Pron, and I'm here with Drew Ray and we're from the Safety Science Innovation Lab at Griffith University in Australia. Welcome to the Safety of Work Podcast. In each episode, we ask an important question in relation to the safety of work or the work of safety, and we examine the evidence surrounding it.
[00:00:41] David Provan - cohost: And we did a series on just culture, um, on the podcast based on the book titled Just Culture by Sydney Decker. And those episodes were 64, 65 and 66, uh, a few years ago Now Drew. And so I thought we'd, we'd sort of revisit this topic, uh, by looking at a research paper into an organizational change in relation to their just culture model.
[00:01:03] Drew Rae - Cohost: Yeah, it's a little bit scary how long they used a just culture process. Um, I, I guess that's because my safety career in industry was always in engineering style roles. And so when I got involved in investigation, we were sort of automatically looking at the physical system as designed, and the human issues were not typically part of the remit of what we were looking at.
[00:01:29] Drew Rae - Cohost: And then since I've been a researcher, we don't sort of get that insider access unless your disasters happened and things are made public. A lot of these investigations are quiet, they're confidential. Companies are very reluctant to share them. They're often under legal privilege. So really the only just culture stuff I've had a chance to look at was when Derek Hegerty, now Dr.
[00:01:54] Drew Rae - Cohost: Hegerty did his PhD with the lab, um, where he was specifically looking at trying to take a company that used a just culture process and shift that to something more restorative. Yeah. And even that PhD is partially under embargo, so it's not available for other people to look at the details of some of the actual investigations.
[00:02:16] David Provan - cohost: Yeah, I, I, I had a bit more personal experience with, uh, with these models. Drew. I was working in oil and gas for a long time in senior safety roles, and particularly when, when oil and gas went really heavy into, uh, lifesaving rules globally. And so with a set of lifesaving rules in an organization, um, needs to come a individual consequence management process for, um, the breaching of those rules.
[00:02:39] David Provan - cohost: So being in and around these processes in quite some detail, I guess the, I was gonna say the good, the bad, and the ugly, but it's mostly the bad and the ugly with some of these processes. So it's gonna be fun to talk about today.
[00:02:51] Drew Rae - Cohost: Yeah. So, so will we, will we start with just a little bit of history and why it is the oil and gas industry that seems to be very heavily into.
[00:03:00] Drew Rae - Cohost: These just culture models.
[00:03:01] David Provan - cohost: Sure. So, you know, from my understanding, at least in the nineties, uh, gym reason, and you know, so much in safety comes back to to gym reason at a point in time through the nineties, but he sort of published this culpability, I think it was called Drew at the time, a culpability framework for errors, lapses, mistakes and violations, uh, at work.
[00:03:21] David Provan - cohost: And it was sort of the first flow chart style of model to try to understand individual culpability.
[00:03:27] Drew Rae - Cohost: Yeah, and it's a little bit ironic that like a lot of what reason was trying to do was to get away from blaming humans by separating out these categories of errors and showing that there were so many errors that came about for different reasons.
[00:03:42] Drew Rae - Cohost: But the whole framing of it seems to have actually caused organizations to lean in to the blame side of it. So through some quite sort of subtle underlying assumptions and decisions that go into how you set up these frameworks.
[00:03:58] David Provan - cohost: Yeah, I guess, you know, similar with the Swiss cheese model, right? Um, Jim Reason was always trying to explain, you know, the theory of multiple causation, you know, not sort of a, a linear cause effect style situation.
[00:04:11] David Provan - cohost: And again, as industry adopts some of these ideas, maybe with a lack of complete understanding of the underlying science, then, you know, organizations assume that they serve a particular purpose or they corrupt them to serve a particular purpose inside, inside the organization.
[00:04:26] Drew Rae - Cohost: Yeah, so, so we probably should explain the model just briefly.
[00:04:30] Drew Rae - Cohost: This is a podcast, so we can't sort of like show the visual format. A lot of our listeners I think will recognize this as soon as we start to explain it, hopefully others can sort of flow along. This is sort of like a flow chart. So we make a se ask a series of questions, and for each question, it's got a yes or a no.
[00:04:49] Drew Rae - Cohost: That takes us on to different steps. Yeah. The first question is, were the actions as intended? And if the answer is yes, you then say, were the consequences and intended. And if like you took actions intentionally intending bad things to happen, then you're a saboteur. This is not a safety.
[00:05:06] David Provan - cohost: Yeah. Like I, I, I, I cut Fred's, uh, harness, you know, hoping that the next time he put the harness on, it wouldn't work and he'd, he'd fall to the ground.
[00:05:13] David Provan - cohost: Right. So that's what we're talking about there.
[00:05:16] Drew Rae - Cohost: Gambling, most of the time the actions were not as intended or the consequences were not as intended. So we go onto the next question, which was, were you under the influence of an unauthorized substance? And if you were, we ask whether this is because of a medical condition or for some other reason, and we take action accordingly.
[00:05:35] Drew Rae - Cohost: If the answer to that is no. We asked, did you knowingly violate safe operating procedures? And if you, did we ask why? You, was it because of the procedures were a problem or was it because you just weren't
[00:05:48] David Provan - cohost: following them? Yeah. So you just go, I, I know I, I know I should have got a permit to do this job, but I, I didn't get a permit.
[00:05:54] Drew Rae - Cohost: And if the answer to that one is no, then we apply a thing called the substitution test, which is basically asking in hindsight, do we think that someone else in the same situation would've made the same decision? And if yes, then we think this is probably something to do with the system. If no, then this is probably something to do with the person.
[00:06:14] David Provan - cohost: So, so Drew and, and, and there's so many variations of these, you know, Patrick Hudson went on to sort of expand and, and, and deepen this like he did with, you know, Ron West's cultural work. And obviously, um, Patrick Hudson was very, um, close in the early two thousands to the Shell Oil company, particularly around lifesaving rules and, and these types of bottles.
[00:06:36] David Provan - cohost: So I guess that's part of the reason why oil and gas going back 20 years, drew really. Lent in heavily to sort of, you know, these, these frameworks.
[00:06:46] Drew Rae - Cohost: Yeah. And, and we have to bear in mind that this was like, not just reason, trying to avoid blame, it's the reason why most companies adopt these frameworks is they're deliberately trying to improve their investigation processes and to make them fairer.
[00:07:03] Drew Rae - Cohost: It's just that they have some quite unintended consequences when you lay it out like this. And we can probably wait till as we get later into this particular paper 'cause they lay out pretty well the main sort of underlying issues that cause these processes to look really fair on paper, but on practice not to be very good at actually leading towards improving safety within an organization.
[00:07:27] David Provan - cohost: Yeah. So sort of processes, imagine processes done. So, so Drew, let's, let's introduce the paper and then get, let's, let's talk about, you know, what was done and what was learned as a result.
[00:07:37] Drew Rae - Cohost: Sure. So, so the paper is called From Individual Behavior to System Weaknesses, the Redesign of the Just Culture Process in an International Energy Company, a case study.
[00:07:49] Drew Rae - Cohost: So we have a Triple barreled title. Something I tell my students constantly, don't, do you, you get one colon, a new title. But no, they, they've gone for all three. Um, the authors are all from, all from BP at the time that this was written. It's no secret that the International Energy Company. Is BP and the authors are, uh, FAZ Beta, uh, Diane Chadwick Jones, Maron Nak and Chan Bhai bha, uh, FERS Beta or Fuzzy Beta is still at BP and is currently their senior Vice President for HSC and Carbon.
[00:08:28] Drew Rae - Cohost: Um, he has a PhD in Human Factors from University of Aberdeen, which does a lot of, uh, they're very well known for safety research in the oil and gas industry. Diane Chadwick Jones was director of Human performance at bp. She's no longer with bp, but while she was there, she was one of, I think, pretty much the earliest early adopter of the sort of new view hop safety to human factors principles, trying to implement them within an organization rather than as a.
[00:09:02] Drew Rae - Cohost: You know, a lot of this stuff comes from consultants. BP had this team within the organization really developing and using these ideas. At the time, Diane's now a very influential speaker, speaker and mentor, um, in the safety space. And Chan Budha is also still at BP as Chief Industry Officer. So yeah, these are very, very senior people within the organization.
[00:09:27] Drew Rae - Cohost: Safety, uh, the paper was published in 2018 in the Journal of Loss Prevention in the Process Industries. This is quite a reputable journal, but it focuses mainly on the technical side of safety, in process safety. So, you know, lots of stuff about pipe, corrosion and explosions, but they also occasionally publish some of this safety management stuff so long.
[00:09:49] Drew Rae - Cohost: It's specifically about oil and gas or chemical process industry.
[00:09:54] David Provan - cohost: Do you wanna just sort of introduce the method and then we'll get, we can, we can sort of both get into the co content.
[00:09:59] Drew Rae - Cohost: Sure. So as you can probably tell from the authors, these are the people within the company who tried to make the improvement.
[00:10:06] Drew Rae - Cohost: Now writing a paper about the improvement, um, there is nothing wrong with that. As an industry case study describing what they've done, it's really useful for them to reflect on what they did, why they did it, what the results were really useful for other people to hear. Unfortunately, there's no good avenue for publishing that kind of stuff.
[00:10:28] Drew Rae - Cohost: So what tends to happen is those case studies get written up with pseudo research methods, and in this case they've called it action research. And the paper starts off with a couple of pages you're describing and justifying what action research is and why it's legitimate. Just for absolute clarity.
[00:10:44] Drew Rae - Cohost: What they did is not action research, it doesn't have any of the core elements that make action research. A legitimate research methodology. This is an industry case study done well as that. I just hate it when journals make people wrap things in this method methodology in order to publish it. Um, I don't think it improves the frank and honest description of what people did, why they did it, and what they found out.
[00:11:12] Drew Rae - Cohost: So what did they do? They took their existing process. They did a number of things to interrogate that process. They had some interviews with staff. They did some interviews with other companies about their own pro, about their process and what sort of made a good process. They did a deep dive into the relevant literature and they critically examined the documentation and the practice of their process.
[00:11:38] Drew Rae - Cohost: David, would you agree that that's sort of a
[00:11:39] David Provan - cohost: Yeah, absolutely. And, and in at the end, I guess to fast forward to the very end, they do, researchers do sort of suggest the opportunity for further research, um, you know, particularly, specifically ethnographic research and similar, and I actually think that this paper could have, and, and I'm sure that they were doing a lot of, you know, conversations and data gathering, but a little bit of sort of structured ethnography would've added a lot of, I guess, depth to the current state.
[00:12:05] David Provan - cohost: In the paper, like we don't get a lot of depth into the, the current situation and the problem within the organization, except for a few tables with a few case dump study numbers and a few findings. So Drew, just as you were sort of sharing that, I thought, gee, it would've been really good to get the detailed current state about what was actually going on with this process in the organization.
[00:12:25] Drew Rae - Cohost: Yeah. The, the, there's sort of two things that give rigor to this sort of insider stuff is one of them. The deep ethnography so that you've got lots of data coming from people in the organization who are not the researchers
[00:12:40] David Provan - cohost: or the managers maybe.
[00:12:42] Drew Rae - Cohost: Yeah. And then the other thing that makes action research really good is you have multiple cycles.
[00:12:49] Drew Rae - Cohost: So each cycle is the test of your understanding of the previous cycle. If you only go through one cycle, then there's no way to really validate your conclusions. The. Your way to validate your conclusions is you feed them into the process and go round again and again. And each time you go round you refine your understanding of what's happening at the same time as you're improving it.
[00:13:11] Drew Rae - Cohost: If you only get one cycle, you can sort of speculate as to what the improvement was, but you can't really test it.
[00:13:17] David Provan - cohost: So you kind of need Drew like an an individual worker or contractor inside the organization to do something and go through a just culture process and then change it and wait for that same person again to, to go through the just culture process again and, and try to evaluate whether or not the experience of the process or the outcomes was different.
[00:13:36] David Provan - cohost: You know, the second cycle through, um, or something. And I know that's sort of like a, a, a fictitious type scenario, but when we talk about action research, that's what we're really, we're really talking about is actually implementing a change and then res observing, you know, the result of that.
[00:13:51] Drew Rae - Cohost: Yeah. And, and unfortunately, what's good for a company isn't always good for research.
[00:13:56] Drew Rae - Cohost: You know, in research terms, the ideal is to make one change at a time and then go through the next cycle. In company terms, you wanna fix everything at once, so you make lots and lots of changes, and as a result you get perhaps quicker improvement, but you've got no idea what actually caused the improvement and less certainty that the improvement even actually existed in the form that you think it did.
[00:14:18] Drew Rae - Cohost: So, you know, there's this constant tension between trying to achieve rapid organizational change and trying to generate knowledge and you can't be perfect on both.
[00:14:27] David Provan - cohost: No, so, so let's talk about this as a bit more of an organizational change process with the relevant research and and safety science inputs into that process.
[00:14:35] David Provan - cohost: So, we're gonna talk through what the old process was that was in place prior to the, the change within b within bp. Um, the organization we're gonna talk about what the researchers felt was wrong with their old process. We're gonna talk about what the literature said about these processes and how it related to what they were doing, and then the changes that they, they made, and then how they reflected on the outcomes.
[00:14:59] David Provan - cohost: Or their evaluation of the change once they had implemented, implemented it. Um, so Drew, do you wanna start by, by us talking about, you know, the existing process in the organization? And we're going back almost a decade now. This, this paper was published in 2018. So, you know, nothing we're gonna say is necessarily reflective of the current state within BP today.
[00:15:19] Drew Rae - Cohost: Oh, well, well we know it's not reflective of the current state because this is before they change the process. They might
[00:15:24] David Provan - cohost: have changed it back Drew. We dunno.
[00:15:27] Drew Rae - Cohost: And remembering that in part, part of the challenge is that the way these things actually happen is not how they're on paper. So, so this is how it happened on paper is they would start by completing a formal investigation.
[00:15:40] Drew Rae - Cohost: So they do all of the collection of evidence and record it in an investigation report. After that, they then carry out a just culture assessment covering everyone who was involved in the incident. And this includes local HR involved along with safety representatives. In that every individual who's involved gets applied against this just culture decision tree, which is very much how we described it in terms of the James Res and diagram.
[00:16:11] Drew Rae - Cohost: BP was using a slightly modified version of that, which had slightly simplified wording attached to it. Um, they then record the conclusions for each individual, um, and decide any necessary disciplinary action. They then take that disciplinary action, or if it's a contractor, they pass it on to contractor management to force their subcontractor to take disciplinary action against their employees.
[00:16:39] Drew Rae - Cohost: Um, and there are a number of problems with this process. Uh, I love the first one, which is that, uh, they used it in order to dismiss someone who challenged it in court and a court disagreed that this was a just culture process. Um, yeah, the, the court decided that in fact, this is not due process applied to a person.
[00:17:02] Drew Rae - Cohost: So yeah, that was like the underlying purpose in the first place is set up a process that is giving someone, you know, fair treatment. And it didn't pass the sniff test when a court went back and looked at what had happened.
[00:17:13] David Provan - cohost: Yeah, and Sydney Decker always talked about this with his restorative just culture work, where he said, you know, a just culture process requires a presumption of innocence, a jury of peers, and a right to appeal.
[00:17:24] David Provan - cohost: And in all of these just culture processes inside organizations, it's usually not a presumption of innocence because there's an incident that's happened and I'm applying this process. Um, there's not a jury of peers. It's a manager who gets to decide and there's no right of appeal, um, or a chance to defend yourself.
[00:17:39] David Provan - cohost: So it sort of decided and handed down to you. So it doesn't surprise me drew that a, that a court would say. You these, this isn't a, a process of justice.
[00:17:50] Drew Rae - Cohost: Yep. The second problem is something that also tends to be universal with these processes, which is, and that they use very careful wording here. They say in some locations the workforce has perception appeared to be, which is, I'm just gonna say in a lot of organizations, this is just the way it is, which is that this doesn't get done to managers.
[00:18:10] Drew Rae - Cohost: This gets done to frontline staff. You know, it's supposed to be every individual involved, but obviously it can't be because, you know, HR is running the investigation, the safety team is running the investigation, you know, when was the people involved include the safety people or the people involved includes the people who wrote the procedures.
[00:18:28] Drew Rae - Cohost: It, you know, it tends to be the frontline people or at most the supervisor of the frontline people. Gets run through the process. So it's seen as singling out those people. Um, and it's seen as something which is justifying disciplinary measures rather than deciding them. And this is something that Derek found in his PhD as well, that there's almost like a shadow process that has already decided the outcome.
[00:18:51] Drew Rae - Cohost: And then we go through this tree as a way of documenting and justifying the outcome. We don't genuinely interrogate these questions.
[00:18:58] David Provan - cohost: And I think there's also a few, um, comments in here about what, what I'd consider to be just general implementation issues with a process like this. They talk about a lack of training, a lack of, you know, governance and oversight and quality management and monitoring and, and those types of things.
[00:19:14] David Provan - cohost: So I think Drew, any process that you put in place your organization, in your organization that doesn't have these quality management aspects is, is likely to be something that drifts away from its intended purpose.
[00:19:26] Drew Rae - Cohost: Yep. And then this is another thing that's fundamental to these processes, unless you sort of like consider the alternatives.
[00:19:33] Drew Rae - Cohost: It can be kind of hidden. Every single outcome from the process is some sort of statement about disciplining a person even when it's not disciplining a person. That's still the focus.
[00:19:47] David Provan - cohost: Yeah. No action to be taken. What
[00:19:48] Drew Rae - Cohost: type? Yeah, what type of discipline? Running from zero to. Fire them and everything is somewhere in between.
[00:19:55] Drew Rae - Cohost: None of the outcomes of this process are focused on anything other than punish the person in some way.
[00:20:02] David Provan - cohost: And I think Drew, that's a process design issue saying that we're using complexity science or what Professor Woods or someone would say is that a system does what it's designed to do. It's just not always what the designer intended.
[00:20:12] David Provan - cohost: And I think you know this, this is, these are very much processes that are designed around cul. The original process was a culpability framework, um, which is a process that's designed specifically to understand levels of individual culpability. So I think Drew, for me, this you sort of reflection then is that this process is doing exactly what it's designed to do.
[00:20:32] Drew Rae - Cohost: Yes, and, and I think on paper the assumption is, well, we've got this other process, which is the investigation that deals with the other stuff. And then after the investigation we do this. Which is the bit that just focuses on the behavior, but the real world doesn't work like that where you design two independent processes and expect the people participating in the investigation to be ignoring the existence of the just culture process.
[00:20:57] Drew Rae - Cohost: Um, you know, it's gonna shape everything that happens because we know that this is coming.
[00:21:02] David Provan - cohost: So, drew, let's talk a little bit more about the literature then, because the, this paper act, this paper did quite a good job of going through the literature and not just the safety science literature, but sort of a little bit more, more broadly into sort of the psych psychology literature and so on.
[00:21:17] David Provan - cohost: Just to try to sort of see how, um, individuals, organizations, you know, navigate or work with these types of processes. So do you want to sort of pull out some of the literature highlights?
[00:21:27] Drew Rae - Cohost: Sure. The, the, the first thing I wanna notice is like the literature that's critical of the just culture processes include some of the authors who are most responsible for these processes.
[00:21:39] Drew Rae - Cohost: So, you know, Hudson is one of the key promulgators of just culture style models and has also been one of the biggest critics of those models. And I think that sort of like goes to the fact that it's possible to recognize the weaknesses in these things and try to fix them and still just end up perpetuating the same system.
[00:22:00] Drew Rae - Cohost: Because the problem's, not the detail, the problem is the underlying assumptions of what you're doing. So the first problem is that just looking at the picture, it basically implies that individuals are guilty until they can prove innocence. The way the flow chart cascades is basically start at the guilty end and you've gotta survive every question until you get to the far end.
[00:22:21] Drew Rae - Cohost: And at that point we decide that you're innocent. So it just like immediately puts you into this frame of mind of let's work out how guilty they are. It doesn't have a clear process to. How do you make sure that supervisors, managers, and executives are held accountable at face value, very much is about pick an individual and that individual is likely to be the person who is directly involved in the accident.
[00:22:43] Drew Rae - Cohost: Very narrow concepts of what could have been the causes. So you know, these words like violation, even though we might divide them into, you know, unintentional or personally motivated or company motivated, it's still actually quite a very narrow and confusing space to be in. So it's really quite hard to disentangle that someone might have done things for quite sensible reasons.
[00:23:08] Drew Rae - Cohost: We're sort of assuming that an error is an error, it's something they've done wrong. For some reason this doesn't fit into broader standards of justice. This is something that Hudson pointed out originally and then Deca really doubled down on that. You know, all of the elements that we'd normally look for in something that was deli designed to deliver justice isn't there and it going, it's gonna tail what people report.
[00:23:31] Drew Rae - Cohost: How people perceive the process, the level of stress and anxiety people have when they're doing tasks or when they're, if something goes wrong, how they respond during the investigation. And then there's the psychology around it, which is a lot of this wording in terms of the order people get information and the way the questions are phrased is almost like designed to promote things like hindsight bias and second guessing decisions based on the outcomes, or turning things into moral judgments rather than looking at the system or trying to understand what really happened.
[00:24:08] Drew Rae - Cohost: You know, there's a kind of intrinsic assumption that people do quite often deliberately do bad things, and that's just not accurate to the way people typically think. You know, even people who commit outright crimes usually aren't like. So-called bad people trying to do bad things. And yeah, by the time you get to a workplace accident, this idea that there are like good people and bad people, and people who are just like recklessly indifferent people around them isn't really the case.
[00:24:36] David Provan - cohost: I think Drew also just maybe outside of the, the literature, just a, a personal experience that I, that I had with a, an event like this, and I'm keen for your take on, uh, management applying this process. So what happens typically is that, uh, the incident, um, investigation happens, this process starts, and it's a safety person or an investigator sitting down with a person from human resources sitting down with a relatively senior manager or middle manager and working out, working their way through this model, right?
[00:25:07] David Provan - cohost: And applying all of their own judgements over the top. And I was involved in an event where, uh, a couple of individual workers had, let's say, worked. Significantly outside the work procedures and the rules. And given the context of that situation, when explained to other team members or other workers at the same level, they unanimous unanimously said, yeah, we would always work like that.
[00:25:32] David Provan - cohost: And then when the supervisor, when I asked a supervisor about that work, they said, oh, I can see how they might've done that, but they really know that they shouldn't have. And then when it got up to the, the superintendent or the the manager level, they said, no, no, this would be an exception. You know, our workers wouldn't work like that.
[00:25:50] David Provan - cohost: They know not to work like that. And, and what then at the senior management level, the response was Absolutely not. People who choose to work like that shouldn't, are choosing not to work for our company. So as, as I, I actually intentionally went up all of, you know, five or six levels of management and, and asked them to make that judgment.
[00:26:07] David Provan - cohost: So it's really important to remember that when you get asked that question in this framework, like, could someone in a similar situation have made the same decision? That is, I, I don't even know the right language for this, but that is a ridiculous question to ask a manager about what they think a worker would do.
[00:26:26] David Provan - cohost: I just think it's ridiculous.
[00:26:28] Drew Rae - Cohost: And, and if you, you just like wanna take that question seriously. The way to do it is to go and find lots of other similar situations. And to find out what people do. Yeah. And so what asking people is just a dumb way to answer that question.
[00:26:42] David Provan - cohost: Yeah. Well, my example of what, what, what I did as part of that event, because we really wanted to understand it, was actually went to five different work groups who all had no idea about this situation and, and talked them through the scenario and asked them, you know, what would you have done in this situation?
[00:26:57] David Provan - cohost: And they all unanimously said, this is what we would've done. So like you said, drew, so, so I don't know any organizational just culture process that actually tries to answer these questions genuinely, which means it's just managers sitting around a table making assumptions, like you said at the start.
[00:27:12] Drew Rae - Cohost: And e even sort of like getting beyond that judgment of the behavior. Notice how already even in our own conversation, we are focusing so much. On judging the behavior, and we claim that, you know, we are not about individual behaviors, we're about like underlying causes and system things, but this whole process is putting the behavior, not at the start of the process, but front and center of our conversations about the process of our judgments, about the process, about our effort, about, you know, who's involved in the process, what people are thinking about.
[00:27:48] Drew Rae - Cohost: So that, you know, we might try to push beyond the behavior, but we've already used up so much of our energy and detention in that framing around the behavior.
[00:27:57] David Provan - cohost: Yeah. It's like your point, drew. So we've got an incident investigation that should hopefully go to, you know, the entire system. And then we take one tiny little snapshot, which is, you know, the actions of an individual or group of individuals.
[00:28:10] David Provan - cohost: And that becomes the sole input for this process. And then we sort of draw in, you know, selective information on the way through. But you know, the object of inquiry is the individual behavior, right? Like that's what the process is designed, designed for. So, you know, we'll get to practical takeaways at the end, but, you know, trying to expand that back out is an interesting challenge to actually, you know, make the process to do something different to what it, I guess is, is front and center designed to do
[00:28:37] Drew Rae - Cohost: so.
[00:28:38] Drew Rae - Cohost: So we mentioned a few different ways they're investigating. They were. Talking to people in their own company, they were looking at the literature and they were also benchmarking against other companies. And we probably won't go into too much detail 'cause the other companies in the Benchmark review said very similar things to what they found in their own organization.
[00:28:56] Drew Rae - Cohost: You things like it's important to apply it to all levels of the hierarchy to have some sort of escalation process. The language tends to lean towards disciplinary actions and it's really important to manage the qualities and to actually look at how this process is applied rather than just sort of like having it as non-paper process.
[00:29:17] Drew Rae - Cohost: And assuming that people understand what you mean by.
[00:29:20] David Provan - cohost: Let's, let's talk about the redesign process and, and go from there. So they, they read it, so they designed a new flow chart, and in the paper it's a, it's a new flow chart with eight questions that get asked about. So we talked at the start about different, drew, you went through from Jim Reasons, model A, a bunch of questions.
[00:29:36] David Provan - cohost: So they, they redesigned, uh, a range of questions. So should we, should we just run through these eight questions and just sort of see the, the new language and the new questions that were being asked?
[00:29:48] Drew Rae - Cohost: David, you've got better eyes than me. I might need you to actually read out the questions.
[00:29:52] David Provan - cohost: That's okay.
[00:29:52] David Provan - cohost: I've made it a bit bigger, so yeah, let's, let's go The starting point, I guess the framing for this was, you know, basically anyone using this process to be really clear on what are the BP expectations that you're testing the individual's actions against. So it's not just, I think, I think this person should have done something different.
[00:30:10] David Provan - cohost: It's really clear around what are these company expectations that we are testing, you know, the, the situation against. So the first question is, is asking whether or not the, the, the people involved were instructed or influenced to do something by their supervision or a manager or another person in authority.
[00:30:27] David Provan - cohost: So, obviously, I guess drew the intention here is if a supervisor's go and go and do this job like this and the work group go off and do it like that, then that's kind of on, on the manager, right? That's not really on the, on the work group to start with. So,
[00:30:42] Drew Rae - Cohost: yeah. And that's something that's oddly missing from reasons, original process.
[00:30:46] Drew Rae - Cohost: It's not No, no. Nowhere in there at all. You know, the intention is that you might apply the original process to the supervisor as well, but it doesn't automatically help the person who's done the action. And this sort of makes it clear immediately that, you know, if you were told to do it, then yeah, you've got very limited blame attached to you for following the instructions of someone who had authority to tell you what to do.
[00:31:10] David Provan - cohost: Yeah. So the second question is about the clarity of expectation. So it, it, it says exactly that. So was the expectation clear? You know, was there a procedure, uh, a clear instruction for the work? Was it available? Was it current? Was it workable in that situation? Um, so you. Is it fair? Is it fair for us to form the view that the people were really clear about what, what should have been done?
[00:31:34] David Provan - cohost: And we're starting really to start to, you can see how we start with the management supervision. And even by this second question, drew, we're straight to judgments about what the people knew about what they should have done.
[00:31:46] Drew Rae - Cohost: Yes. Although I should point out that another feature of this is the outcome here is not about the discipline.
[00:31:53] Drew Rae - Cohost: So the outcome that they've got is about, you know, working with people to clarify those misunderstandings. So at least it's not saving you, not culpable and focusing on the culpability. It's focusing on what's the best way to improve based on what the situation was. So they, they're trying really hard to steer this using the choice of language and the choice of outcomes, that this is less about judging behavior.
[00:32:18] David Provan - cohost: So, so the third question, drew, is, you know, if, assuming the expectations are clear, did the people involved understand what was required? Did they have the knowledge, experience, skill, um, physical capacity and resources to do it? So I guess it's, it's one thing to have the expectation, it's another thing to have, um, all of the time, knowledge, equipment capability to be able to meet that expectation.
[00:32:40] David Provan - cohost: So did they have everything they needed to, to do the work in that way?
[00:32:44] Drew Rae - Cohost: Although, I have to admit David at this point, I'm really wondering how do you actually find the answer to that question? I'm, I'm imagining this really does involve like sitting someone across the other desk, across the desk and asking them, and there, there's, you know, there, there's not really a way to separate, were the procedures clear from, did the person understand the procedures?
[00:33:03] Drew Rae - Cohost: Except by whether you think the person's honest when they say, I didn't understand.
[00:33:07] David Provan - cohost: And then the detail here tries to get into things like selection, training, assessment of the people involved. And, you know, I, I, I, I, I think this is where intention and application are probably going to, to deviate because, you know, the designers of this process, you know, probably would wanna look at, you know, the, the selection, the onboarding, the induction, the supervision, the oversight, the, the equipment maintenance and all of this stuff.
[00:33:30] David Provan - cohost: But, you know, going through this process, I, I can't really see a, uh, a manager going, oh, actually I'm gonna look at the last 50 people that I hired and see if there's any issues with the selection and the induction and the onboarding of my people. Like, you know, it's, this is. This is starting to expand back out towards an investigation an an incident investigation process, drew, but I'm, I'm not sure that that's how companies would, would follow this process.
[00:33:54] Drew Rae - Cohost: The next one is, did they intend to act in line with BP's expectations but made a mistake? And this one is interesting because, I mean, I have a lot of the respect for the individuals involved in both the writing the paper and in designing this. But this is like directly contrary to what the literature says.
[00:34:13] Drew Rae - Cohost: One of the things that the literature pointed out is that you don't wanna start blurring the just culture with performance management. And to answer this question, they're directly looking at the person's past history of errors. And this is one of the ways in which just culture gets very much entangled with discipline, is we start judging people's current actions on how did we perceive them as an employee and how well have they been performing previously?
[00:34:38] Drew Rae - Cohost: And have we blamed them in the past for mistakes? And people can very quickly get into this pattern of we are using the just culture process to justify this is the last straw.
[00:34:49] David Provan - cohost: Yeah. And the next one, drew, is, um, about, which I quite like, is actually, were they following customer practice, which is common amongst peers, which is, okay, well an incident happened today, but the way that the group was working is just the way that, you know, this work always happens.
[00:35:03] David Provan - cohost: So it almost starts to look at understanding normal work. So, you know, the idea here is that as part of this process, now we're at question number five is, is this the way that this work is normally done yet maybe there was a different outcome this time.
[00:35:17] Drew Rae - Cohost: Yeah. And I like the fact that they've completely separated this from procedures.
[00:35:21] Drew Rae - Cohost: So they've already asked the procedures question, how is it meant to be done? And this is a separate question, meant to be thought about separately, forget about the procedures. Is what they were doing, just the way it's normally done.
[00:35:31] David Provan - cohost: Then there's a little bit of, I guess, consistency with the previous, so the, so there is still a substitution test here, question number six, which is could another person with the same knowledge, skill, experience have done the same thing in the identical situation?
[00:35:43] David Provan - cohost: I'm not sure you need that substitution test Drew, if you do the normal work and the, and the, and the procedural thing, because if, if the procedure's unclear or if it's custom in practice, then you've sort of already got your answer for the substitution test. So, you know, I, I really don't know if I like asking one person to make determinations about what they think another person would do in a particular situation.
[00:36:05] Drew Rae - Cohost: Yeah. The, the, the substitution test is one of the most heavily criticized things in a literature that examines just culture processes because we know that it's not a question that people can answer effectively. Yeah. It's a question that almost deliberately invokes hindsight bias. What I do like is there is a subtle change that they've said, could another person have done the same thing rather than would another person have done the same thing you would?
[00:36:36] Drew Rae - Cohost: Another person is absolutely hindsight, depending on how you train, train people to do this. If like the intent is we've already looked at the procedures, we've already looked at normal practice. What we're asking now is just apply your imagination. Could you imagine a reasonable person might have a reason to do this?
[00:36:53] Drew Rae - Cohost: Try to think of reasons and ways someone else might do this, and if you like, train people with the right way to think about that. Maybe this could be a sort of like last ditch escape that you've already at risk of blaming the person, but now you're really forcing yourself to imagine maybe there's a way to do it.
[00:37:11] Drew Rae - Cohost: I would rather something like, you know, deliberately putting in the question here, try to explain a reason why this person. Might have thought that what they were doing was reasonable. Because I think almost anything, if you try to do that hard enough, you can explain why what they did did actually make sense to them.
[00:37:29] David Provan - cohost: Yeah. Drew that principle of local rationality, right? People in organizations aren't just randomly making decisions, right? They're doing in that situation what they think is the best course of action at that point in time. And I think that's what hopefully, you know, the core intent of this proce process, if it, you know, I would almost rename the process, don't call it a just culture process, call the whole process a local rationality process, right?
[00:37:49] David Provan - cohost: And the whole process is about asking questions that tries to understand the local rationality for, you know, the action and your thoughts about, we'll talk about language in a little bit shortly, drew, but this next question here, question seven is probably my favorite question, which is, right, and not the way it's worded, but it's intent.
[00:38:06] David Provan - cohost: It says, is there evidence to suggest that the. Person or team acted to help themself the company to save time or effort. And this goes, this is the extension of the local rationality. So many of the workarounds and adaptations to work are about achieving another goal. You know, a schedule goal, a production goal, a cost goal, you know, a productivity goal or something like that.
[00:38:31] David Provan - cohost: And so many times, and things that I've seen Drew in in my career has been, oh, when you really need to get this machine back online. So we don't have the time to get the permit, we've just gotta get it back up and running. Now that's nothing about the individual, that's about just trying to act in at that point in time what the, in what the team think, you know, the company needs them to do.
[00:38:51] David Provan - cohost: And so, yeah, drew, I, I actually really like that because I would challenge anyone to. I think if you tried hard enough, like you said before, drew, that you can find a reason why the person was actually trying to help the company.
[00:39:05] Drew Rae - Cohost: And then, then the final one is, is there evidence that they intended to cause harm, damage or loss?
[00:39:11] Drew Rae - Cohost: And I, I love the way, by putting this question last, rather than putting it first, they then like skip the whole rest of the framework and just say, this is a special case. Consult hr. And they sort of like make it clear that this is like a almost ridiculous outlier.
[00:39:28] David Provan - cohost: And, and it's interesting because it'd be really interesting if you got there because you still gotta answer the other one.
[00:39:33] David Provan - cohost: 'cause the one that I used for this example a little bit is, I think there was a, there was a case in Queensland, maybe over a decade ago where of, of a prosecution that was a result of an a new employee initiation activity where a particular workplace, the new employee would get a little bit of flammable liquid placed on them and they get set on fire as a bit of an initiation.
[00:39:54] David Provan - cohost: Uh, ritual. But the interesting thing for this framework, drew, is that yes, there was evidence to suggest it was, you know, quite intentional, but it was actually custom and practice. It was something that was done for, uh, for every new person. So kind of don't quite know how you'd answer that, but you know, in this case, the person got a little bit more burnt than normal, so it turned into a, a legal matter.
[00:40:16] Drew Rae - Cohost: The interesting thing is because they reordered the framework, they would never have got to the last question. In that case, they would've off ramped it. The is this normal customer and practice and this, this, I'm really curious about. 'cause they don't answer this later in the paper. It's possible to get through all of these questions and still drop off at the end, and they've got a little red box at the end which says, it's not clear why this happened.
[00:40:40] Drew Rae - Cohost: You, it's possible to get the process and there's no explanation, which I think is often honestly the case in investigations is the behavior doesn't make sense to us and maybe it just doesn't. And instead of defaulting to. Therefore the person's blame, which is what would happen under the normal process.
[00:40:57] Drew Rae - Cohost: You get to the, that end and it's just, okay, you've gotta may, maybe you need to investigate further 'cause we just really don't know.
[00:41:02] David Provan - cohost: Yeah. And so I think Drew, there's, there's eight, there's eight new questions here. That, and, and you, you know, sort of some more explanatory information about how to work with these questions.
[00:41:11] David Provan - cohost: I still really feel like it's still directed at the individual. So even that question I said I really liked about evidence to suggest they acted to help themself or the company. You know, the action to take, if you answer yes to that is something like. Work with individuals involved to reinforce the appropriate behaviors and consult with HR for advice on disciplinary measures.
[00:41:31] David Provan - cohost: It sort of doesn't say take action to reduce the goal conflict within the system, or it, it, so there's, there's still no real direction in this framework, even though we're starting to ask more system orientated question, there's no, there's no direction on how to intervene at a system level. You know, all of the direction is still how to intervene at, at the individual level.
[00:41:51] David Provan - cohost: And we'll talk a little bit about in, in a moment as well with, with the outcomes of this revised process.
[00:41:55] Drew Rae - Cohost: Yeah, I, I, I, I, I understand that the intent really is that the investigation process, which is supposed to be decoupled from this, it's supposed to be the bit finding those system improvements. So, you know, it was never the intent of the just culture process to do anything other than judge behavior, but yet they're still got this big step which judges behavior.
[00:42:19] Drew Rae - Cohost: And the hope is that because this step is fairer. That it will have less adverse impact on that previous investigation step that people trust this, feel more secure, more likely to answer questions honestly and helpfully in that earlier investigation process. Leading to the system improvements. But as we're, as we're gonna find out from the findings, I don't think that's the case.
[00:42:43] Drew Rae - Cohost: I think we still have. Really strong evidence that this judgment of individual behavior is still gonna color up the whole process.
[00:42:50] David Provan - cohost: Yeah. So, so drew the key changes. So, so changing the framework itself and the questions that get asked and the process flow, and also changing the, where the process happens in relation to other processes.
[00:43:01] David Provan - cohost: So, you know, decoupling it from, from disciplinary processes or investigation processes and really just trying to look at this just culture process in, in isolation with a new set of questions. Is the major, the major change here. So let's talk about evaluating the new process. So following the process, it looks like this process was redesigned in 2016, and so there was 353 cases that they reviewed following the new process.
[00:43:25] David Provan - cohost: So it's like they rolled out this new process and then started to see what was happening. And this is where we don't have much pre and post data through, so we don't actually have. Data sets to, to match up against each other. The research has suggested initially, you know, 50% have been classified as mistakes.
[00:43:45] David Provan - cohost: Um, so that one question, did they intend to act in line with expectations but made a mistake? So it was question number four. Um, and then what it looks like they did Drew, although the details were a little bit sparse in the paper, is it looks like they got a culture or a safety culture subject matter expert to sit down with these 353 cases and based on the information available, do some sort of desktop reclassification.
[00:44:09] David Provan - cohost: So say this is what manager and HR came up with, but now let's actually re reevaluate this. And when they reevaluate it, they, instead of having sort of 50% mistakes, they only ended up with 21% of these, uh, incidents being classified as mistakes. So true. Initially I thought that they were doing sort of a pre-post thing, but then when I read it about four times, I sort of realized that they're actually.
[00:44:36] David Provan - cohost: Using the, the post change data set, but reanalyzing what the initial review found, if that makes some sense.
[00:44:43] Drew Rae - Cohost: Yeah. Da David, I read that multiple times and I'm still not clear whether these are incidents that happened before or after the new process was implemented. And I think that's really important given that one of their key findings is that the process doesn't happen as the way it's described on paper.
[00:45:03] Drew Rae - Cohost: So doing a desktop reanalysis using the new process doesn't get at the heart of the problem, which is how does this system actually impact real people going through an investigation who know that they're about to be just cultured? And that's gonna take time to have the new process in place to have people's understanding, to have the stories that people tell about that process change in order to evaluate how does that affect the investigation process from start to finish?
[00:45:33] David Provan - cohost: A And so Drew, I, I, I actually think on, on reading that it was cases post change and they were actually doing a quality review of what the process was determining versus what they were expecting it to determine. And this doesn't surprise me. An organization, the size of BP trying to roll out any change with, um, capability and consistency is incredibly challenging.
[00:45:55] David Provan - cohost: So, you know, but it'll go to show that, you know, maybe it's a hangover from the old system or maybe it's a, a, an issue with the implementation. But, um, it appears as though that the sys the, the, the process maybe could have done what it was intended to do, but maybe wasn't doing what it was in intended to do at, you know, at the start.
[00:46:13] Drew Rae - Cohost: So, so they do have a sort of like central claim that they say that it did shift the type of corrective actions taken, following the incident that their old process tended to result in human focused outputs. So training, coaching, or discip. All of which are like clearly squared at an individual. And the new process, they say emphasizes system defects such as.
[00:46:38] Drew Rae - Cohost: Poor quality of procedures or
[00:46:41] David Provan - cohost: equipment. And I think drew in the results. And, and this is the cha and, and we'll talk a little bit in a moment. A again, about what you look for is what you find in that principle. But even post the, the change, you know, the actions were still like 40% coaching, 7% training. And the author sort of said, yeah, the coaching piece, that's 40%.
[00:47:00] David Provan - cohost: A lot of that coaching was in, was about reinforcing expectations, but also about, which I particularly didn't like Drew because I don't think this is the intent of the change, but a lot of coaching about making sure individuals speak up. When they're unclear on the expectations or unsure about what to do.
[00:47:18] David Provan - cohost: So it was almost like we're not blaming you as an individual, but we are gonna coach you to speak up when you don't actually know what you, you, you need to know to do the work. So it's, it's, it's a process directed individuals and I don't think that the process can be re re redesigned away from the individual.
[00:47:36] David Provan - cohost: Like I just find that at the very end of the, the paper drew, we still kind of got a little bit back to the, the start when we look at kind of like what was happening.
[00:47:45] Drew Rae - Cohost: Yeah. Yeah. I, I don't think if your system problem is, we are not leaning hard enough onto individuals to behave correctly, that you are really doing system thinking
[00:47:56] David Provan - cohost: and particularly if your system intervention is about trying to promote a system where people speak up when they haven't been provided with something.
[00:48:04] Drew Rae - Cohost: Yeah. And I think that's particularly problematic in something like oil and gas where so much safety. Really is tied to physical equipment and the management of that physical equipment. You know, if you are in an environment like construction where a lot of safety really relies very heavily on individual behaviors, you know, you can change the tool that's in someone's hands, but ultimately it's a very human action using the tool, the the focus that like what we need to fix is constantly the behavior instead of we need to improve the environment people are working in and the underlying.
[00:48:41] Drew Rae - Cohost: Processes that that equipment forwards.
[00:48:43] David Provan - cohost: And I think Drew, this is the, the big challenge. Like I, I actually think the intention of this was, was, was great. I think the, the effort was, was really good. I think those revised questions are pointing in the right direction. And then when we see the outcomes, even though we are saying that, you know, this is great because 79% of these cases have now been classified as system induced errors, over 80% of the actions as a result of those system induced errors are at the individual level, clarifying expectations, training, coaching, discipline.
[00:49:15] David Provan - cohost: Only 17% of the actions are about work planning processes or equipment changes. So even though we, it's like the 80 20, we can say that 80% of these things are being classified as system errors, but then 80% of the actions are individual. So it's, it is just a, it is just a, maybe it's just a reality of this process, right?
[00:49:34] David Provan - cohost: Like it just can't be redesigned away from the individual intervention.
[00:49:38] Drew Rae - Cohost: Yeah, I, I guess you have to sort of look at this in two ways. One of them is, this is all that the process can possibly do, right? It's a human focused process. All it can do is focus on the human. The real question is what effect does that have on other processes?
[00:49:52] Drew Rae - Cohost: So, you know, if by being fairer, by being less likely to blame, it allows you to have your investigation process and your human factors process and your design processes to have better engagement with the frontline, more honest communication, then maybe you will actually see those other improvements outside this process.
[00:50:11] Drew Rae - Cohost: 'cause you, this process doesn't have a step for redesign the tank. You replace the gauge. That's not what this process is for.
[00:50:18] David Provan - cohost: And Drew, I think that's where the, the researchers then in, when they talk about evaluating the outcomes of this process, they, they quite broad in their, their feelings about the contribution that this process redesign had in the broader organization.
[00:50:32] David Provan - cohost: And they talk about following this process, they released a set of human performance principles for their organization that changes the way that management think about safety and the way that managers think about the role of people in relation to safety and work. So Drew, I think following from your, your comments there, I think, you know, looking at this from a research point of view, looking at this one specific process and going, what's the rigor around the change in this one specific process is kind of like some of the comments that I was making.
[00:51:00] David Provan - cohost: And then what you are sort of talking about is what does this process then do in terms of, you know, the, the integrated system of, of safety and work, right. And, and culture. Um, and maybe it's got those big impacts elsewhere.
[00:51:12] Drew Rae - Cohost: Yeah. And it is one of those annoying paradoxes in safety research that. Possibly the biggest impacts are the things that are hardest to measure.
[00:51:22] Drew Rae - Cohost: Yeah. There is no way the individuals running this case study can objectively evaluate those broader impacts. You know, of course the people in the organization are going to think that they had a positive cultural impact, but that's also where the big improvement comes, is from insiders working hard to create those big changes.
[00:51:40] David Provan - cohost: And I think the interesting opportunity though, that still exists for organizations, like, if you're thinking of doing this type of work, and I'd encourage organizations to do this type of work. I think Fuzzy and Diane and, and Mars and, um, and, and their colleagues, I, it's wonderful that they make this work available to, to the broader industry is you can still do more to try to evaluate like Drew in that respect.
[00:52:02] David Provan - cohost: If we thought, one of the hypotheses was that if we redesign this just culture framework, as managers got exposed to this framework, they would maybe change their understanding of the role of individuals in, in accidents. Then you could design a 10 question survey for managers across the whole of BP and understand, you know, what they currently believe or, or think about the role of individuals and then.
[00:52:26] David Provan - cohost: After each manager gets exposed to the revised just culture process, you can then resurvey them about what they think about the role of individuals in behavior. So I still, and I don't know about that from a research design, but I still think there's ways of us trying to test whether or not, you know, the, the system's changing.
[00:52:42] Drew Rae - Cohost: Oh, an organization the size of BP with the budget they have. Even just for making this one particular change, I just wanna fly on the wall, independent investigator chatting to people, watching what's going on, sitting in on a few of these processes from start to finish as like just independent ethnography examining how all of the pieces of this are changing and fitting together.
[00:53:07] Drew Rae - Cohost: Because yeah, it's fantastic that such senior people are involved in these sort of changes and in the research that no one is gonna honestly tell them what they're really thinking about the process.
[00:53:18] David Provan - cohost: Yeah. So, drew, are we ready to do practical takeaways? Sure. Okay. So do I. Where do you
[00:53:25] Drew Rae - Cohost: wanna
[00:53:25] David Provan - cohost: start?
[00:53:25] Drew Rae - Cohost: Oh, okay.
[00:53:26] Drew Rae - Cohost: Well let, let's start with where we just finished, which is one of the big challenges we have here is safety is an emergent property of lots of things that happen in the organization. It's the work that happens, the environment, the work happens in the team that's around you, the tools that they have. And it's kind of inevitable that we are gonna always start at that level of individual behavior.
[00:53:50] Drew Rae - Cohost: 'cause often that's closely tied in to the accident that happened. But if our process leans us to stick at that and center that behavior, it's gonna be really hard. No matter how well we design the process to get beyond it. And to get up to that system improvement, we really need to be asking questions about the system rather than questions about the behavior.
[00:54:11] Drew Rae - Cohost: If it's a system we wanna improve.
[00:54:13] David Provan - cohost: Yeah, drew, I think it's that, as Sydney Decker would say, it's the up and out viewpoint rather than the down and in viewpoint. And I think, you know, we want to observe individuals. In our organization. Like that's how we understand how our organization is functioning. But that's what we actually wanna do.
[00:54:27] David Provan - cohost: We, we actually wanna understand how our organization functions. So any process, whether it's your just culture process, your incident investigation process, your plan task, observation process, your, your audit and inspection process, whatever, whatever those processes you have of observing and monitoring or understanding what people are doing in your business should really only serve to understand how the system is producing that behavior.
[00:54:49] David Provan - cohost: Um, and then if you want to actually change, if you wanna make your organizations much safer, then you need to change the system so it produces a different behavior. If you're just sort of intervening at the individual level, then you're not really making your organization that much safer, I guess is the takeaway.
[00:55:02] Drew Rae - Cohost: Takeaway number two, I wanna be very clear that David wrote this because out of 130 episodes, I think this is about the hundredth time. I've said this, if you're gonna invest so much in making change within your organization, put a little bit of the budget into evaluating it properly. There's so much work to improve and.
[00:55:21] Drew Rae - Cohost: The quality of the data on has it actually worked is very unsatisfying despite all the effort they put in upfront to design the change, to understand the change, to get data to inform the change. To make the change.
[00:55:34] David Provan - cohost: Yeah. And in this, in this paper, you know, there's, there's a lot of claims about the significance of the change as a result of what was done.
[00:55:43] David Provan - cohost: And it was prefaced by the team saying like, you know, based on our feeling of the change, uh, and like you said, you sort of, sort of marking your own homework. I think there's so many opportunities with any organizational change process to stop and think about how well do we understand the current situation and how are we gonna know if we've made things significantly better?
[00:56:05] David Provan - cohost: And there's always ways of answering tho those questions. And if you don't, I guess know it, um, drew, drew will be able to help you with an organizational research design for that.
[00:56:14] Drew Rae - Cohost: And the third one, which is the big positive out of this, which is when you've got something that is so fraught, like a just culture process, the little details matter, the choice of words, things like violations.
[00:56:26] Drew Rae - Cohost: The way you draw the diagram and the what sort of centered in the diagram, the order you ask the questions, all of those are gonna have an impact as to how people are thinking through the process and whether it's sort of gonna default towards blaming people or default away from blaming people.
[00:56:45] David Provan - cohost: And I think Drew another takeaway that I'd, I'd probably like to test with you as well.
[00:56:50] David Provan - cohost: Um, and it sort of connects to the safety clutter research. Like if we think about a just culture process and you know, going through a process to try to understand what discipline we should apply to a person, it probably meets the definition of clutter, which is a, a safety process or practice that doesn't add any value to operational safety.
[00:57:06] David Provan - cohost: Like, I think we can sort of say that I talk a lot about redesigning processes, like maybe the answer to safety clutter is not throw something in the bin, but just think about how it can be redesigned. And in this episode today, it just got me thinking about maybe the solution for something like this as a just culture process is.
[00:57:23] David Provan - cohost: Maybe there's limits to the extent to which you can actually redesign a process to be materially different. And we've talked a bit about that today. And, and maybe this is a candidate, like a just culture process is actually a candidate for just throwing it in the bin. Not redesigning it, not replacing it, but just don't have it anymore.
[00:57:39] David Provan - cohost: Like if you've got a good incident investigation process, do you actually really need anything else?
[00:57:44] Drew Rae - Cohost: I, I, I, I think that's one of the key problems here is you've got an incident investigation process, which is supposed to be getting at the system factors. You've got an HR discipline process, which is supposed to be dealing with discipline.
[00:57:58] Drew Rae - Cohost: Is there actually a value add for something in the middle? I don't think that's a gap that an organizational needs. I think this was a gap that was artificially created by James reason. Um, and the actual better thing is to improve your investigation process and to improve your HR processes, not to try to have this culpability framework tying the two.
[00:58:19] Drew Rae - Cohost: Together, but just to have good processes.
[00:58:21] David Provan - cohost: Maybe if we think about in the nineties, you know, there was, there was the rise of, you know, more organizational effort on incident investigation more broadly. And you know, there's a HR process around performance management that's coming and there's a, there's a point in time 30 years ago where actually we need to bridge these processes because we learned some things in investigations and we, you know, we've got people in HR thinking that, you know, we need to manage that performance.
[00:58:43] David Provan - cohost: And so we create this. And then, you know, I think with, with our understanding of safety in 2025, yeah, just one thing as we went through today and, and preparing for today, that I thought actually there are limits to which we can materially redesign processes that are actually fundamentally intended to do a particular thing.
[00:59:00] David Provan - cohost: And we've actually gotta ask ourself is do we need that thing to be done in our organization? Um, and my takeaway here is probably not, probably, probably, it's something you can just. Walk away from.
[00:59:11] Drew Rae - Cohost: Yeah, no, I do have a lot of sympathy with, it's very hard to remove processes entirely. I just think in this case there are other processes you already have that overlap into that same space that you don't have an organization of vacuum that would need to be filled if you just got rid of it.
[00:59:27] David Provan - cohost: And most of these revised questions, those eight questions we went through about understanding normal work and goal conflict and trade offs and supervisors and managers, they're all questions that should be answered in the investigation anyway. Like you shouldn't get to the end of invest the investigation and and, and not have the answers to those things that are in this revised process.
[00:59:45] David Provan - cohost: So
[00:59:46] Drew Rae - Cohost: I'm just gonna sneak in and say the question we asked this week was, what are the problems with just culture models? What's the short answer, David?
[00:59:52] David Provan - cohost: I think the problem with the just culture model is that we have a just culture model. So amongst the other things that we mentioned during the episode.
[00:59:58] David Provan - cohost: So thanks Drew. That's it for this week. We hope you found this episode thought provoking and ultimately useful in shaping the safety of work in your own organization. Send any comments, questions, or ideas for future episodes to us via LinkedIn or feedback at safety work com.