The Discourse of Just Culture in Safety


The Discourse of Just Culture in Safety

­­­imageOne of the most important skills in Critical Discourse Analysis (CDA) is to look and listen to text-narrative and consider critical language omitted. Discourse is about power embedded in language, discourse is just about the flow of conversation and text. In CDA it is just as important to consider what is NOT said as what IS said. To find out more about CDA look here:

One of the foundational skills in the Social Psychology of Risk is CDA. CDA is essential for finding: hidden agenda, philosophical assumptions, motive, perception, ontology, ideology and intent in text-narrative.

One of the first things we look for in CDA is definition.

We need to be suspicious and sensitive to the following in risk and safety: assumptions about meaning, lack of definition, naïve use of language, silences, semiotic association, the framing of discourse, politics hidden in Discourse and unethical non-disclosure of motive/ownership that is essentially dishonest.

In most Discourse in safety there is much that is assumed without any definition. On most occasions behaviourist-positivist assumptions are never declared and presented in authoritarian manner so as not to be questioned. Such as the recent paper presented by the ASSP as if it is about leadership: https://safetyrisk.net/guaranteed-non-leadership-in-safety/

So, with this in Mind, let’s have a look at what Safety says about ‘Just Culture’.

The idea of Just Culture can be traced back to James Reason in his 1997 book Managing the Risks of Organizational Accidents. In a section entitled ‘Engineering a Just Culture’ (pp. 208ff) we already know by the title that Just Culture is NOT about Justice or Culture. So often the code of Safety (https://safetyrisk.net/deciphering-safety-code/ ) is the opposite of what is spruiked as propaganda, and this work by Reason is no exception.

There is no correlation between any discourse on culture with engineering, just as there is no such thing as ‘engineering resilience’ (https://safetyrisk.net/why-resilience-cannot-be-engineered/ ). When you don’t disclose your mechanistic and behaviourist assumptions in text this is the kind of nonsense Safety believes makes sense. Of course, Reason doesn’t define culture in his book despite using the word hundreds of times.

In a similar way, the AIHS BoK Chapter on culture (10.2) omits to mention many critical elements of culture. This is not surprising when the non-disclosed ethic in the AIHS chapter on Ethics (framed as duty) omits every critical element of ethics and is not honest in owning or naming its own assumptions/disposition!

The first thing we note about Reason’s work is that he doesn’t mention ethics in relation to justice. How amazing because there can be no talk of justice without a foundational discussion of ethics.

Similarly, Reason makes no mention of politics and yet any discussion of politics is essential to understanding Justice.

Instead, Reason assumed that Justice is about ‘punishment for error and unsafe acts’ (p.205). It is also clear that Reason is primarily concerned with ‘bad behaviours’ NOT the nature of persons, human Mind or being.

When you read this from Reason (p.205): ‘A prerequisite for engineering a just culture is an agreed set of principles for drawing the line between acceptable and unacceptable actions’, you know that Reason has no interest in either Justice or Culture.

This is followed by pseudo-behaviourist discourse masked as psychology. How amazing to discuss the nature of human action with no reference to the unconscious, heuristics, ethics or fallibility!

Similarly, the semiotics presented on page 206 is simplistic behaviourist nonsense. There is no discussion at all in the mentioning of ‘intention’ about perception, ethic, power, unconscious or will. It is clear in this simplistic discourse that intent is somehow something obvious. How amazing when most of us don’t even know what our own intent is! As Weick so rightly stated: ‘I don’t know what I believe until I see what I do’. (The Social Psychology of Organizing).

So, for the purpose of this discussion by Reason doesn’t need to define Ethics or Justice and in so doing creates confusion because it makes no differentiation between the Law, the Courts and the policing of regulation.

Justice is about the humanizing of persons.

Justice can only emerge out of a humanizing ethic.

Justice is not focused on safety but rather the whole person in the common life. You cannot get a sense of what Justice is from framing life through safety. Similarly, you cannot know what Justice is if life is framed through systems. Justice is neither interested in measurement or engineering. Justice can never be ‘engineered’.

There is a huge difference between the activities of the legal profession, the courts and jurisprudence. Jurisprudence is concerned with the philosophy of law and stands apart from the systems and practices of law. Just have a listen to the discourse of Greg Smith and the focus is on legal proceedings not a philosophy of justice (https://vimeo.com/showcase/3938199; https://safetyrisk.net/risky-conversations-free-download/ ). Indeed, we may call ‘the legal system’ – ‘the justice system’, but it’s primary interest is NOT Justice.

When Reason (p. 207-213) discuses negligence error, blame, judgment, behaviours, his ‘decision tree’, non-compliance, punishment and reward, he is NOT talking about Justice.

When one considers Justice as the outworking of an ethic, we ought to consider Justice as a disposition not a system.

Similarly, when thinking about culture. Reason discusses culture and justice as if they have ‘components’ that can be ‘engineered’ (p,195). What Reason is concerned about is ‘an atmosphere of trust’ that ensures ‘essential safety-related information’ and ‘acceptable and unacceptable behaviour’. None of this is about Justice. No wonder Reason thinks Justice can be ‘engineered’.

Of course, Safety has picked up on the idea of ‘Just Culture’ from Reason because it knows and has experienced safety as brutalism. The trouble is, it doesn’t know what to do. So, Just Culture has become symbolic in the industry about balance between accountability and responsibility and ‘the right thing to do’. It then masks all its ritualistic activities as actions for Justice.

And, what this poorly educated industry ends up with is, confusion regarding Justice and Ethics mixed up as duty and ‘check your gut’ (https://safetyrisk.net/the-aihs-bok-and-ethics-check-your-gut/ ).

When accidents are defined as ‘evidence that a particular risk was not managed well enough’ (Dekker p.ix Just Culture) there is no longer room for consideration of the unconscious or fallible personhood. Justice then becomes about ‘management’ not about the centrality of personhood. Because ‘accidents are no longer accidents at all. They are failures of mismanagement’ (p. x)

So, this leaves Safety as ‘the protector of individuals in systems’ and this has nothing to do with Justice.

As Ricoeur states, an ethic of care/helping ought to be held in tension with Justice as the humanization of persons. What Bruggemann calls ‘Justice from below’.

There can be no Ethic of Justice without an understanding of power, something you won’t see countenanced or discussed in the AIHS BoK on Ethics. Similarly, you won’t find any discussion of politics or power wherever Safety talks about ‘Just Culture’.

When we consider the nature of power (in Discourse), the first question brought into view by CDA is: Who is justice for? If this discourse is about justice for systems, then it’s not about Justice but rather the protection of regulation.

Have a look at this:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776518/

and it opens with:

‘The framework of a just culture ensures balanced accountability for both individuals and the organization responsible for designing and improving systems in the workplace. Engineering principles and human factors analysis influence the design of these systems so they are safe and reliable’.

and this is typical of Just Culture Discourse, the focus is NOT on persons but the improvement of systems (read Technique).

Or this:

https://www.brighamandwomensfaulkner.org/

it opens with:

“Just Culture” refers to a system of shared accountability in which organizations are accountable for the systems they have designed and for responding to the behaviours of their employees in a fair and just manner.

Again, the focus is systems, accountability and behaviours NOT about the humanizing of persons.

Just Culture proudly announces that it never asks ‘who’ but it asks ‘what?’ (https://www.youtube.com/watch?v=yWhb4vLIegM ) as if this is what makes safety both objective and balanced.

The opposite is the case.

Whenever we focus on ‘what’ (hazards and systems) we can never deliver Justice as the ethical humanization of persons.



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