We have arrived in the new year. Who knows, perhaps you, dear readers of this blog, have resolved as leaders to confront error with a different attitude and to refrain from blaming. It certainly won't be long before your resolution is put to the test and wants to be mastered as a challenge. It might come across like this:
Let's say one of your employees carelessly clicked on a link in an email that enabled a hacker attack on your company. You are currently discussing in management whether or not to pay the ransom to the attackers. Moreover, you know which employee made the consequence-laden click. You yourself keep calm and listen to the comments in the board. Somebody will certainly say it - and there it comes. One of your business management colleagues says, "If the employee had tried a little harder and been mindful enough at work, it wouldn't have happened"!
You are prepared for this blaming. And yet, an uncomfortable thought creeps in, unsettling you. Suspicion. You know the employee and, in view of what has happened, you are not quite sure whether she has not fallen victim to her leisure-oriented protective attitude, which is sometimes latently shining through. Was there even a lack of interest in the work? Was her attitude toward work the reason for the mistake with its devastating consequences?
There are managers for whom the suspicion of a non-intact inner attitude quickly resonates and reinforces their belief that an accusation is justified. This then no longer refers to the actual misconduct but rather to the suspected reprehensible attitude behind it. Neither gross negligence nor even intent are apparent in the present case, because the hackers had done a good job; the mail came across as quite professional. Thus, the concerns are dedicated to the possibly inadequate attitude of the employee. Unfortunately, there are no objectively observable criteria to prove such an attitude. It remains with the assumption, which can also be an insinuation.
A culture of honesty shows the way
In this example, we see two important things that are important for successful cooperation in a safety culture. If employees show doubts about their intact inner attitude and or if managers fail to give priority to the question of WHY when dealing with errors, then things will go wrong. An effective and firmly anchored safety culture is based on a contract, the honesty deal. It says that employees will make an honest effort to do a good job and that in return, managers will deal honestly with the team's mistakes. Therefore this safety culture is also known in German as 'Redlichkeitskultur'. In English, especially in aviation, the term 'Just Culture' has become established. The Anglo-Saxon expression indicates that in such a culture, mistakes are dealt with in a just manner. In this context, just means that not only the failure of the employee is judged unilaterally, but that the contributory factors that were effective in the systemic context are also included and analyzed to the same extent. In a Just Culture, the actors strive for a balance between learning (recognizing weaknesses in the system) and responsibility (holding the fallible individual accountable).
The common practice of measuring with two cubits
Ultimately, however, learning is also about responsibility. Because as we know, systemic shortcomings are involved in every unintentional event that occurs. Managers are responsible for many of these systemic shortcomings. But they are usually not up for discussion in case management. Especially not when it comes to sharing responsibility for systemic weaknesses. Because whenever learning is involved, this generally refers to those who are at fault and who have to work on themselves. So, in every unintentional event we would have enough reasons to blame both the management of a company and the employee who was partially responsible. The fact that we don't do this when answering the question of guilt and only ever concern ourselves with the responsibility of the individual is reprehensible and certainly not honest. Fortunately, the question of guilt does not matter in the context of improving safety. Because, as we can see, it can't fix it. Our laws as well as the administration of justice (and unfortunately still many executives) assume a general preventive effect of punishment. It is assumed that safety is thus improved. Those who think this way have an irritating view of human beings. They see people as risk factors and thus fail to recognize that they are the greatest enabler of safety. If every employee of a high reliability organization had an account in which risk-minimizing actions were paid into and risk-promoting actions were deducted, they would all be multimillionaires, figuratively speaking, at the end of their careers.
Moreover, the administration of justice is one-eyed. It prefers to see only the person at the sharp end whose action implicates him or her in the incident. It does not recognize nearly as accurately all those responsible for the imperfect system that provides the context for the employee's work. That's where the laws are blunt and the will to bring the weak approaches to bear is lame. Fortunately, when it comes to safety, it's all about finding root causes, not assigning blame. Since Just Culture is not based on laws, it can claim to be just. And that, in turn, works surprisingly well because in a Just Culture, both management and the individual do not have to face the question of blame when dealing with unwanted events. Both can devote themselves to finding the causes without fear, and each party can learn the lessons for itself.
An approach that builds trust
Let's return to your employee who made the fatal click. Back to your suspicion that she has an inadequate inner work attitude. Your skepticism toward her is nothing more than a dire suspicion that the employee has not lived up to the honesty deal. Do you take this as a reason to break the contract yourself? Does this suspicion give you a free pass to deal dishonestly with the employee's proven unintentional honest mistake? It's your choice. You are on the edge with your Just Culture, and you can push it into the canyon with a judgment. What is more important to you? Having the employee's full support in finding the root cause, which she will give you if you don't scare her. Or the satisfaction of a verdict with negative consequences for the person involved, which signals to everyone who is the cock of the walk. Is the light that shines on you when you exercise power particularly bright? What are the real reasons that push you into the role of judge? Is settling the question of guilt more important to you than figuring out how to protect the company from further hacking? Is it conceivable to you that the employee's unproven protective attitude could be the effect of systemic causes for which you also share responsibility? Do you manage to address these questions or do you remain trapped in the old paradigm, which sees the problem with the human being, helpfully eliminates it quickly and frees you from having to face unpleasant questions, which on top of that even make you so annoyingly aware of your co-responsibility for the system?
What happened could be an unprecedented opportunity to strengthen your relationship of trust with this employee. It has the potential to confirm and further develop the company's Just Culture. This culture needs leaders who are willing to take on the challenge. Leaders who rise to the challenge and who know their role in safety. Superiors who know they can't delegate the safety of the organization to a safety department. Because culture is what you do as a risk owner, not the safety specialists.
As you can see, good New Year's resolutions can have a big impact if they are able to pass the litmus test that everyday life always holds in store.