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:

• (00:00) Introduction to just culture models and their problems
• (03:00) Historical context of Jim Reason's culpability framework and industry adoption
• (07:37) Introduction to the BP case study research paper and methodology
• (15:19) Existing BP just culture process and its implementation problems
• (21:27) Literature review findings on just culture model weaknesses
• (29:20) The eight question redesigned BP just culture framework
• (43:25) Evaluation of the new process and classification outcomes
• (53:25) Practical takeaways and system versus individual focus
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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:

Link to the Paper

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