Can a Just Culture Save Us?
Lately, there has been much discussion of “just culture” in the wildland fire community. Until recently, much of the debate and discussion has centered on the investigations into the Cramer and Thirtymile fires.
The argument frequently went something like, “If we had a just culture, we wouldn't be filing criminal charges against firefighters.”
That line of reasoning caused me to question whether we firefighters understand just culture well enough and if we might be stretching the concept beyond what the underlying theory supports. But a conversation recently has begun that may improve the fire community's understanding of just culture and what a just culture might do to improve organizational learning in fire organizations and firefighter safety.
In the interest of full disclosure I wish to make two things clear. First, I'm no expert on just culture, but I study organizational learning and leadership and have read up on just culture, as I am sure many readers have. Second, I believe that criminal prosecutions, both actual and threatened, have proved counter-productive both to organizational learning and to firefighter safety. From my perspective, criminalizing what may be unavoidable human error without first fundamentally changing the approach to fire fatality investigations will continue to hinder our ability to learn from tragedy, consequently impeding firefighters' safety.
In his 1997 book Managing the Risks of Organizational Accidents, James Reason describes a just culture as “an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior.” Just-culture experts, most of whom come from the aviation safety field, distinguish between a just culture and a culture of blame, arguing that individual blame too often obscures the larger organization's role in accidents. I've found that most authors in the aviation safety literature make reference to “just culture” in the context of voluntary, non-punitive near-miss or error-reporting systems, all of which could improve firefighter safety. Still I am concerned.
Take the argument that if we had a just culture, we wouldn't be filing criminal charges against firefighters. Well, I'm not so sure. Let's not conveniently forget that while a just culture avoids blame and punishment of individuals in support of learning from unsafe acts, it also establishes a bright line between acceptable and unacceptable behavior. Yes, just-culture experts distinguish a just culture from a blaming culture, but they also distinguish between a just culture and a “no-blame” culture, which the experts reject as both impractical and undesirable. In a just culture, organizations still hold people accountable, culpable, even legally liable, if they engage in willful misconduct, reckless behavior, gross negligence, criminal acts and other behaviors that the given culture finds unacceptable. A just culture would not preclude firefighters found culpable of unacceptable behavior from facing discipline.
A just culture treats organizational and human errors as organizational learning opportunities, not as ways to avoid accountability for unacceptable behavior. However, we can expect that with a just culture in place, mistakes, errors and unsafe acts committed by firefighters falling above the line of unacceptable behavior would not result in discipline or punishment. However, my concern lies with firefighters who appear to be arguing for a no-blame culture or who are seeking solely to shift the blame from individual firefighters to the organization. In my opinion, those arguments hurt the cause of advancing a truly just culture, and people coming from these perspectives will find little support from the just culture experts.
My concern grows when I consider the obvious: U.S. wildland fire agencies have not established that “bright line” that enables everyone to know what constitutes unacceptable behavior, nor have they established a systematic approach to determining culpability. Instead, the fire community seems to be letting courts, lawyers, the bereaved and others decide for us and make up our standard for unacceptable performance on the fly. I contend that fire agencies must develop standards for behavior and performance and establish that clear line between unacceptable and acceptable performance, and that they must do so collaboratively, involving agency personnel both broadly and deeply.
It seems to me that just culture provides part of the solution. If fire organizations are to minimize firefighter fatalities to only those that are unavoidable in an inherently dangerous occupation, we must get serious about our organizational learning and establish a learning culture. Unfortunately, our current investigatory culture is focused on finding fault and assigning blame, and it discourages organizational learning rather than encourage it. Both research and practical experience in other high-risk industries suggest that a just culture enables and sustains organizational learning from unsafe acts.
I'm big on the high-reliability organizing principle of deference to expertise. If we want to bring the concept of just culture to life in fire organizations and we want to know whether just culture can solve our problems and how, we need to have the experts advise us rather than rolling our own. I understand that leaders in the interagency fire operations safety community have proposed to do just that, and this is a positive development.
Mike DeGrosky is chief executive officer of the Guidance Group, a consulting organization specializing in the human and organizational aspects of the fire service. He also serves as an adjunct instructor in leadership studies at Fort Hays State University. His interests include leadership, strategy, and bringing the concepts of learning organizations and high-reliability organizing alive in fire organizations. He is currently pursuing a Ph.D. focused on organizational leadership. He can be reached at info@guidancegroup.org.
