Search results for: just-culture-balancing-safety-and-accountability

Just Culture

Author : Sidney Dekker
File Size : 24.9 MB
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Building on the success of the 2007 original, Dekker revises, enhances and expands his view of just culture for this second edition, additionally tackling the key issue of how justice is created inside organizations. The goal remains the same: to create an environment where learning and accountability are fairly and constructively balanced. The First Edition of Sidney Dekker’s Just Culture brought accident accountability and criminalization to a broader audience. It made people question, perhaps for the first time, the nature of personal culpability when organizational accidents occur. Having raised this awareness the author then discovered that while many organizations saw the fairness and value of creating a just culture they really struggled when it came to developing it: What should they do? How should they and their managers respond to incidents, errors, failures that happen on their watch? In this Second Edition, Dekker expands his view of just culture, additionally tackling the key issue of how justice is created inside organizations. The new book is structured quite differently. Chapter One asks, ’what is the right thing to do?’ - the basic moral question underpinning the issue. Ensuing chapters demonstrate how determining the ’right thing’ really depends on one’s viewpoint, and that there is not one ’true story’ but several. This naturally leads into the key issue of how justice is established inside organizations and the practical efforts needed to sustain it. The following chapters place just culture and criminalization in a societal context. Finally, the author reflects upon why we tend to blame individual people for systemic failures when in fact we bear collective responsibility. The changes to the text allow the author to explain the core elements of a just culture which he delineated so successfully in the First Edition and to explain how his original ideas have evolved. Dekker also introduces new material on ethics and on caring

Just Culture

Author : Professor Sidney Dekker
File Size : 69.92 MB
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Building on the success of the 2007 original, Dekker revises, enhances and expands his view of just culture for this second edition, additionally tackling the key issue of how justice is created inside organizations. The goal remains the same: to create an environment where learning and accountability are fairly and constructively balanced. The First Edition of Sidney Dekker’s Just Culture brought accident accountability and criminalization to a broader audience. It made people question, perhaps for the first time, the nature of personal culpability when organizational accidents occur. Having raised this awareness the author then discovered that while many organizations saw the fairness and value of creating a just culture they really struggled when it came to developing it: What should they do? How should they and their managers respond to incidents, errors, failures that happen on their watch? In this Second Edition, Dekker expands his view of just culture, additionally tackling the key issue of how justice is created inside organizations. The new book is structured quite differently. Chapter One asks, ‘what is the right thing to do?’ - the basic moral question underpinning the issue. Ensuing chapters demonstrate how determining the ‘right thing’ really depends on one’s viewpoint, and that there is not one ‘true story’ but several. This naturally leads into the key issue of how justice is established inside organizations and the practical efforts needed to sustain it. The following chapters place just culture and criminalization in a societal context. Finally, the author reflects upon why we tend to blame individual people for systemic failures when in fact we bear collective responsibility. The changes to the text allow the author to explain the core elements of a just culture which he delineated so successfully in the First Edition and to explain how his original ideas have evolved. Dekker also introduces new material on ethics and on caring for the’ second victim’ (the professional at the centre of the incident). Consequently, we have a natural evolution of the author’s ideas. Those familiar with the earlier book and those for whom a just culture is still an aspiration will find much wisdom and practical advice here.

The Just Culture Principles in Aviation Law

Author : Francesca Pellegrino
File Size : 60.68 MB
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This book reviews and critically analyzes the current legal framework with regard to a more just culture for the aviation sector. This new culture is intended to protect front-line operators, in particular controllers and pilots, from legal action (except in the case of willful misconduct or gross negligence) by creating suitable laws, regulations and standards. In this regard, it is essential to have an environment in which all incidents are reported, moving away from fears of criminalization. The approach taken until now has been to seek out human errors and identify the individuals responsible. This punitive approach does not solve the problem because frequently the system itself is (also) at fault. Introducing the framework of a just culture could ensure balanced accountability for both individuals and complex organizations responsible for improving safety. Both aviation safety and justice administration would benefit from this carefully established equilibrium.

Implementing Safety Management Systems in Aviation

Author : Alan J. Stolzer
File Size : 40.40 MB
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The International Civil Aviation Organization has mandated that all of its member states implement Safety Management Systems (SMS) in their aviation industries. Responding to that call, many countries are now in various stages of SMS development, implementation, and rulemaking. In their first book, Safety Management Systems in Aviation, Stolzer, Halford, and Goglia provided a strong theoretical framework for SMS, along with a brief discourse on SMS implementation. This follow-up book provides a very brief overview of SMS and offers significant guidance and best practices on implementing SMS programs. Very specific guidance is provided by industry experts from government, industry, academia, and consulting, who share their invaluable insights from first-hand experience of all aspects of effective SMS programs. The contributing authors come from all facets of aviation, including regulation and oversight, airline, general aviation, military, airport, maintenance, and industrial safety. Chapters address important topics such as how to develop a system description and perform task analyses, perspectives on data sharing, strategies for gaining management support, establishing a safety culture, approaches to auditing, integrating emergency planning and SMS, and more. Also included is a fictional narrative/story that can be used as a case study on SMS implementation. Implementing Safety Management Systems in Aviation is written for safety professionals and students alike.

Navigating Safety

Author : René Amalberti
File Size : 80.46 MB
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Managing safety in a professional environment requires constant negotiation with other competitive dimensions of risk management (finances, market and political drivers, manpower and social crisis). This is obvious, although generally not said in safety manuals. The book provides a unique vision of how to best find these compromises, starting with lessons learnt from natural risk management by individuals, then applying them to the craftsman industry, complex industrial systems (civil aviation, nuclear energy) and public services (like transportation and medicine). It offers a unique, illustrated, easy to read and scientifically based set of original concepts and pragmatic methods to revisit safety management and adopt a successful system vision. As such, and with illustrations coming from many various fields (aviation, fishing, nuclear, oil, medicine), it potentially covers a broad readership.

Second Victim

Author : Sidney Dekker
File Size : 71.92 MB
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How do people cope with having "caused" a terrible accident? How do they cope when they survive and have to live with the consequences ever after? We tend to blame and forget professionals who cause incidents and accidents, but they are victims too. They are second victims whose experiences of an incident or adverse event can be as traumatic as that of the first victims’. Yet information on second victimhood and its relationship to safety, about what is known and what organizations might need to do, is difficult to find. Thoroughly exploring an emerging topic with great relevance to safety culture, Second Victim: Error, Guilt, Trauma, and Resilience examines the lived experience of second victims. It goes through what we know about trauma, guilt, forgiveness, and injustice and how these might be felt by the second victim. The author discusses how to conduct investigations of incidents that do not alienate second victims or make them feel even worse. It explores the importance support and resilience and where the responsibilities for creating it may lie. Drawing on his unique background as psychologist, airline pilot, and safety specialist, and his own experiences with helping second victims from a variety of backgrounds, Sidney Dekker has written a powerful, moving account of the experience of the second victim. It forms compelling reading for practitioners, risk managers, human resources managers, safety experts, mental health workers, regulators, the judiciary, and many other professionals. Dekker provides a strong theoretical background to promote understanding of the situation of the second victim and solid practical advice about how to deal with trauma that continues after an event leading to preventable harm or even avoidable death of a patient, consumer, or colleague. Listen to Sidney Dekker speak about his book

Safety and Quality in Medical Transport Systems

Author : John W. Overton
File Size : 77.33 MB
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The Commission on Accreditation of Medical Transport Systems (CAMTS) has been accrediting air and ground transport services since 1991. One of the most significant needs the Commission has recognized is to assist transport services in creating a culture that supports safety and quality for both crews and patients. Most of the helicopter EMS (emergency medical service) accidents and many ground ambulance accidents can be attributed to human factors and systems designs that lead to poor decision-making. Management commitment is vital to create and maintain a culture that supports risk assessment, accountability, professionalism and organizational dynamics. This reference book has been created by CAMTS to address this need directly and comprehensively. It offers a groundbreaking collection of expert insights and practical solutions that can be used by EMS, Fire and Rescue, public and private services, and professional emergency and transport professionals worldwide. Quoting from the foreword written by the late Robert L. Helmreich, Professor Emeritus of Psychology at The University of Texas Human Factors Research Project, 'This is an important book which should be required reading for everyone involved in patient transport, from managers and dispatchers to those at the sharp end... The experienced and able authors and editors of this work use culture as the overarching concept needed to maximize safety while delivering patients expeditiously.'

Patient Safety

Author : Sidney Dekker
File Size : 21.62 MB
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Increased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors perspective, Patient Safety: A Human Factors Approach delineates a method that can enlighten and clarify this discourse as well as put us on a better path to correcting the issues. People often think, understandably, that safety lies mainly in the hands through which care ultimately flows to the patient—those who are closest to the patient, whose decisions can mean the difference between life and death, between health and morbidity. The human factors approach refuses to lay the responsibility for safety and risk solely at the feet of people at the sharp end. That is where we should intervene to make things safer, to tighten practice, to focus attention, to remind people to be careful, to impose rules and guidelines. The book defines an approach that looks relentlessly for sources of safety and risk everywhere in the system—the designs of devices; the teamwork and coordination between different practitioners; their communication across hierarchical and gender boundaries; the cognitive processes of individuals; the organization that surrounds, constrains, and empowers them; the economic and human resources offered; the technology available; the political landscape; and even the culture of the place. The breadth of the human factors approach is itself testimony to the realization that there are no easy answers or silver bullets for resolving the issues in patient safety. A user-friendly introduction to the approach, this book takes the complexity of health care seriously and doesn’t over simplify the problem. It demonstrates what the approach does do, that is offer the substance and guidance to consider the issues in all their nuance and complexity.

Risk Based Thinking

Author : Tony Muschara
File Size : 81.66 MB
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Society at large tends to misunderstand what safety is all about. It is not just the absence of harm. When nothing bad happens over a period of time, how do you know you are safe? In reality, safety is what you and your people do moment by moment, day by day to protect assets from harm and to control the hazards inherent in your operations. This is the purpose of risk-based thinking, the key element of the six building blocks of Human and Organizational Performance (H&OP). Generally, H&OP provides a risk-based approach to managing human performance in operations. But, specifically, risk-based thinking enables foresight and flexibility—even when surprised—to do what is necessary to protect assets from harm but also achieve mission success despite ongoing stresses or shocks to the operation. Although you cannot prepare for every adverse scenario, you can be ready for almost anything. When risk-based thinking is integrated into the DNA of an organization’s way of doing business, people will be ready for most unexpected situations. Eventually, safety becomes a core value, not a priority to be negotiated with others depending on circumstances. This book provides a coherent perspective on what executives and line managers within operational environments need to focus on to efficiently and effectively control, learn, and adapt.

Achieving the Single European Sky

Author : Daniel Calleja Crespo
File Size : 42.56 MB
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This book, the first to cover the SES in depth, presents unparalleled insight into a versatile and complex undertaking which will determine the future of air traffic management in Europe. Its chapters analyse the progress as well as the shortcomings and setbacks encountered in the implementation of the SES policy objectives. With forward-looking contributions from over forty well-known experts working in virtually every arena of aviation, from airports and airlines to regulatory agencies and air law practice and scholarship, the book thoroughly explains what has been achieved so far, not only in theory but in fact.