Near-Miss Incident Reporting – Just Culture

A couple a year ago ASSE conducted its Culture Symposium in Costa Mesa, CA.  One of the speakers,  Joseph Cohen, PhD presented on the concept of  “justice” as it applies to workplace rules and the use of discipline.  Several times during the presentation he referenced Sydney Dekker and his book Just Culture.  I found the topic and Dr. Cohen’s presentation enlightening, so I decided to purchase and read Just Culture.  What an eye-opener!

I couldn’t possibly share all that I learned reading the book in this short post, but suffice it to say that those organizations or institutions that want to improve safety must develop trust throughout and learn from their mistakes.  I liked the discussion of what a learning organization looks like, and the importance of encouraging near-miss reporting as a part of the learning process.  The book also presented excellent examples of how to shut down learning and destroy trust, both detrimental to safety success.

Earlier this month, Mike Williamsen, Phd. with Caterpillar Consulting, Inc., an expert on creating positive cultural change, spoke on Near-Miss Reporting at the Direct Delivery Leadership Council (DDLC) conference in Las Vegas.  Dr. Williamsen summed up the topic very well and shared several important take-aways:

  • In order for any organization to actually improve, it is necessary for it to openly share and learn from its mistakes.
  • Since safety happens at all levels, every one must participate and share their mistakes.
  • Sharing situations that “almost” or “could have” resulted in injury or loss creates opportunities to discuss what happend and to learn.
  • It is very important that there be an open and trusting environment where all near-misses can be reported.
  • Reporting near-miss situations should be encouraged and praised.
  • It is necessary to have a system that evaluates near-misses by severity potential, establishes priorities, and leads to positive corrective action.
  • If reporting near-misses results in disciplinary action or nothing is done to correct high severity potential situations, reporting dies and all related learning stops.

As SH&E professionals we have a terrific opportunity to help our organizations learn and improve.  And in so doing, we will help them not only improve safety, but all aspects of the business.   I think it would be worth your time to find out more about the concepts of a Just Culture and becoming a Learning Organization.   “Just Culture” by Sydney Dekker is a great place to start.

This was Reposted By Request from December 23, 2009.  I hope you enjoy it and comment back with your thoughts.  Thanks.