A ‘Just Culture’ is required to prevent tension or friction by balancing the need for honesty, the want to make diving operations safer, the need for appropriate discipline and accountability and finally, the requirement to ensure that those who make errors are not negatively criticised when they report their mistakes. A Just Culture isn’t just about having a reporting system, but rather a set of beliefs and duties that should be expected from all levels in the diving operation from diver through to organisation/agency. For it to be successful, it is essential that:
•Organisations, supervisors and individuals acknowledge that human error is inevitable;
•Individuals must take a pro-active role in continued diver safety; and finally,
•Everyone, whatever their position in the chain, must know that they will be treated fairly, consistently and objectively by their organisation, agency, the authorities or the diving public at large in the event of an error occurring.
Establishing and maintaining an open and fair reporting atmosphere can and will be difficult; this was apparent from the aviation industry and is currently being faced by the medical professions. Agencies, supervisors and individuals at all levels should encourage frank, candid and honest open reporting to understand why an event happened, not just ‘what happened’. In addition, every effort should be made to avoid action that may prevent future reporting. Reporting should become the norm, not the exception. It is important to note that when considering professionals or those instructing in a voluntary capacity, unpremeditated or inadvertent errors should not lead to disciplinary action, but a breach of professionalism may.
Ultimately, a Just Culture requires a culture change from that currently being experienced. It requires divers to understand that they can report mistakes or errors and by doing so, diving safety can be improved if lessons can be identified and learned. Identifying safety lessons learned is hard and requires the courage to admit you have made a mistake. However, if you don’t report that mistake and someone doesn’t read about it, it can almost be guaranteed that someone else will make the same mistake and maybe the consequences will be more severe.
A Just Culture is only one part of the wider Safety Culture. James Reason in “Achieving a Safety Culture: Theory and Practice”, Work and Stress, 1998. Vol 12, No 3.
“Uttal’s (1983) definition of safety culture captures most of its essentials: ‘Shared values (what is important) and beliefs (how things work) that interact with an organization’s structures and control systems to produce behavioural norms (the way we do things around here)’. The literature (Bate 1992, Thompson et al. 1996) suggests at least two ways of treating safety culture: as something an organization is (the beliefs, attitudes and values of its members regarding the pursuit of safety), and as something that an organization has (the structures, practices, controls and policies designed to enhance safety). Both are essential for achieving an effective safety culture. However, as shall be argued, the latter is easier to manipulate than the former (Hofstede 1994). It is hard to change the attitudes and beliefs of adults by direct methods of persuasion. But acting and doing, shaped by organizational controls, can lead to thinking and believing.”
The emphasis is mine. I can effect a small influence, but it needs those at the top of the diving community organisational chain to change their direction and introduce many of these concepts in their training materials, and the earlier that happens, the better.
Another article worth reading is by Patrick Hudson, entitled ‘Safety Culture: Theory and Practice’. This 12 page report available here contains some excellent references and details about how to improve safety, at the cultural level.