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Book Description

A just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimize the negative impact, and maximize learning? This third edition of Sidney Dekker’s extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, about retributive just culture and about the criminalization of human error. Some suspect a just culture means letting people off the hook. Yet they believe they need to remain able to hold people accountable for undesirable performance. In this new edition, Dekker asks you to look at 'accountability' in different ways. One is by asking which rule was broken, who did it, whether that behavior crossed some line, and what the appropriate consequences should be. In this retributive sense, an 'account' is something you get people to pay, or settle. But who will draw that line? And is the process fair? Another way to approach accountability after an incident is to ask who was hurt. To ask what their needs are. And to explore whose obligation it is to meet those needs. People involved in causing the incident may well want to participate in meeting those needs. In this restorative sense, an 'account' is something you get people to tell, and others to listen to. Learn to look at accountability in different ways and your impact on restoring trust, learning and a sense of humanity in your organization could be enormous.

Table of Contents

  1. Cover
  2. Half Title
  3. Title Page
  4. Copyright Page
  5. Table of Contents
  6. Preface
  7. Acknowledgments
  8. Author
  9. Case Study: Under the Gun
  10. Case Study: When Does a Mistake Stop Being Honest?
  11. Chapter 1 Retributive and Restorative Just Cultures
    1. Retributive Just Culture
      1. Shades of Retribution
      2. Difficulties and Fairness in Retribution
      3. Substantive Justice
      4. Breaking The Rules to Get More Recruits: Some Say Cheating Needed to Fill Ranks
      5. Procedural Justice
      6. Summarizing and Managing the Difficulties with Retributive Justice
    2. Restorative Just Culture
      1. Restorative Justice Steps
        1. Who Was Hurt, and What Are His or Her Needs?
        2. Identifying the Obligations to Meet Needs
      2. Restoration and Forgiveness
    3. Comparing and Contrasting Retributive and Restorative Approaches
      1. Neither Retributive nor Restorative Justice “Lets People Off the Hook”
      2. Retributive and Restorative Forms of Justice Deal Differently with Trust
    4. Can Someone or Something Be Beyond Restorative Justice?
    5. Case Study
      1. Are All Mistakes Equal?
      2. Technical Errors: Errors in a Role
      3. Normative Errors: Errors of a Role
  12. Chapter 2 Why Do Your People Break the Rules?
    1. Labeling Theory
      1. Violations Seen from This Bench Are Just Your Imagination
    2. Control Theory
    3. Learning Theory
    4. The Bad Apple Theory
    5. Stupid Rules and Subculture Theory
    6. Resilience Theory
    7. Case Study
      1. Hindsight and Shooting Down an Airliner
      2. The Hindsight Bias
      3. A Normal, Technical Professional Error
      4. A Normative, Culpable Mistake
      5. Hindsight and Culpability
      6. The Worse the Outcome, the More to Account For
  13. Chapter 3 Safety Reporting and Honest Disclosure
    1. A Few Bad Apples?
    2. Getting People to Report
    3. What to Report?
    4. Keeping the Reports Coming In
    5. Reporting to Managers or to Safety Staff?
    6. The Successful Reporting System: Voluntary, Nonpunitive, and Protected
      1. Voluntary
      2. Nonpunitive
      3. Protected
      4. What If Reported Information Falls into the Wrong Hands?
    7. The Difference between Disclosure and Reporting
      1. Overlapping Obligations
    8. The Risks of Reporting and Disclosure
      1. The Ethical Obligation to Report or Disclose
      2. The Risk with Disclosure
      3. The Protection of Disclosure
    9. What is Being Honest?
    10. Case Study
      1. A Nurse’s Error Became a Crime
      2. At the Supreme Court
      3. A Calculation Gone Awry
      4. “Mea Culpa”
    11. Criminal Law and Accidental Death
    12. Rational Systems that Produce Irrational Outcomes
    13. The Shortest Straw
  14. Chapter 4 The Criminalization of Human Error
    1. The First Victims
      1. Do First Victims Believe that Justice Is Served by Putting Error on Trial?
      2. Are Victims in It for the Money?
    2. The Second Victim
    3. The Prosecutor
      1. What to Prosecute?
      2. Safety Investigations that Sound Like Prosecutors
      3. The Prosecutor as Truth-Finder
    4. The Defense Lawyer
    5. The Judge
      1. Establishing the “Facts”
      2. Determining Whether Laws Were Broken
      3. Deciding Adequate Punishment
    6. Lawmakers
    7. The Employing Organization
    8. The Consequences of Criminalization
      1. Most Professionals Do Not Come to Work to Commit Crimes
      2. Is Criminalization Bad for Safety?
      3. But Isn’t There Anything Positive about Involving the Legal System?
    9. Tort Liability
    10. Without Prosecutors, There Would Be No Crime
      1. The View from Nowhere
      2. There Is No View from Nowhere
    11. Judicial Proceedings and Justice
    12. Judicial Proceedings and Safety
    13. Summing Up the Evidence
    14. Case Study
      1. Industry Responses to Criminalization
      2. Response 1: Do Nothing
        1. Consequences
      3. Response 2: The Volatile Safety Database
        1. Consequences
      4. Response 3: Formally Investigate Beyond the Period of Limitation
        1. Consequences
      5. Response 4: Rely on Lobbying, Prosecutorial, and Media Self-Restraint
        1. Consequences
      6. Response 5: Judge of Instruction
        1. Consequences
      7. Response 6: The Prosecutor Is Part of the Regulator
        1. Consequences
      8. Response 7: Disciplinary Rules within the Profession
        1. Consequences
  15. Chapter 5 What Is the Right Thing to Do?
    1. Dealing with An Incident
      1. Before Any Incident Has Even Happened
      2. After an Incident Has Happened
    2. Not Individuals or Systems, but Individuals in Systems
      1. A Discretionary Space for Personal Accountability
      2. Blame-Free Is Not Accountability-Free
    3. Forward-Looking Accountability
      1. Ask What Is Responsible, Not Who Is Responsible
    4. What Is the Right Thing to Do?
    5. What Can Ethics Tell You?
      1. Virtue Ethics
      2. Duty Ethics
      3. Contract Ethics
      4. Utilitarianism
      5. Consequence Ethics
      6. Golden Rule Ethics
    6. Not Bad Practice, but Bad Relationships
    7. Case Study
      1. There Is Never One “True” Story
    8. Which Perspective Do We Take?
      1. The “Real” Story of What Happened?
    9. Rhetoric: The Art of Persuasion
  16. References
  17. Index