Many organsiations and their leaders and managers struggle with the determination of culpability for errors, ommissions and poor work / decisions that occur in the workplace. Creating a just culture in organisations has been recognised as an essential aspect of organisational development and for increasing accountability and continuous improvement. Central to this is the determination of culpability, a process that helps distinguish between human error, at-risk behavior, and intentional misconduct. By thoroughly investigating incidents and understanding their root causes, organizations can create a fair and transparent system for addressing violations while fostering trust and learning. In this briefing I will look at a recent study looking at how organisations can approach culpability determinations, using clear rubrics and open communication to build a safer, more accountable workplace.
Building on our previous research briefing on the implementation of a just culture in organisations, this briefing looks at an even more recent study looking at a critical aspect that often poses challenges for leaders and managers in a just culture: establishing criteria to differentiate between minor, medium or severe violations, and distinguishing these from genuine errors or system flaws that require organisational change.
This becomes especially pertinent given that a just culture encourages open reporting of mistakes without punitive actions, focusing instead on collective learning and system improvement. As such, having clear criteria for violation assessment is integral to fostering a balanced system of accountability and learning within the organisational setting.
Just cultures
A just culture refers to an organisational culture whereby open communication and learning from mistakes are encouraged, alongside a balanced approach to accountability, enabling the proactive identification and mitigation of risks.
Further, in a just culture, there is a strong focus on accountability, with clear criteria for distinguishing between genuine errors, which are opportunities for systemic improvement, and violations that require disciplinary action.
Previous research studies
A number of previous research studies have, however, identified an issue with the operation of a just culture, in that the criteria for distinguishing between a genuine error and a violation of operating procedures tends to be subjective, based on the individual manager’s standards, preferences and biases.
For example, a 2016 empirical investigation of culpability determination found that decision making is more of a socially negotiated process than many organisations realise, as opposed to a simple application of criteria.
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Previous research studies found
This study found six categories of factors influence the decision as to whether an action was deemed to be a mistake or a wilful or negligent violation:
- Geographical location: The geographical location of the organisation can influence the severity of discipline. For instance, North American sites were found to be more severe than European ones.
- Job role: The job roles of the personnel involved in the decision-making process can also impact the outcome. Engineers and managers were found to be more lenient than operational staff.
- Level of experience: The level of experience of the personnel involved in the decision-making process can also influence the outcome. Experienced personnel were found to be more lenient than their juniors.
- Organisational hierarchy: The level of blame assigned can be influenced by the hierarchical structure of the organisation. Higher levels of blame were assigned to upper-level positions, especially in taller hierarchical structures.
- Demographic characteristics: The demographic characteristics of the individuals involved in the incident, such as race and socioeconomic status, can influence culpability judgements.
- Cultural influences: Cultural differences can also impact culpability assessments. For example, Japanese participants were more likely to hold managers accountable for the errors of their staff, while Americans took a more individualist view.
Other studies – Findings
Other studies have found that other factors, aside from social factors, also impact decisions to ascribe blame or not, including:
- Organisational culture
- National culture
- Characteristics of the person or people making the decisions (personality, etc.)
- The relationship between the person making the decision and the individual under scrutiny
- The type and amount of contextual information available
Why this matters – the Kegworth air disaster
The Kegworth air disaster, in which 47 people died and there were 74 non-fatal injuries, occurred on 8 January 1989 when a British Midland Boeing 737-400 crashed onto the embankment of the M1 motorway near Kegworth, Leicestershire, England. One of the contributing factors to the disaster was the failure of the cabin crew to communicate critical information about the state of the engines to the flight deck.
Factors contributing to communication breakdown
- Hierarchical culture – At that time, the aviation industry often operated under a hierarchical culture, where cabin crew might hesitate to challenge pilots.
- Prior discipline – There was a belief among the cabin crew that they could face disciplinary action for providing potentially incorrect information or challenging the flight crew. This belief was influenced by previous instances of crew members being disciplined for passing incorrect information to the flight deck, although done in the belief it was correct at the time.
- Fear of repercussion: Cabin crew appear to have been hesitant to communicate with the flight deck due to fears of reprisals or disciplinary actions.
The impact of the breakdown in communications
- Incorrect engine shutdown: The pilots shut down the wrong engine, exacerbating the situation and leading to the eventual crash.
- Missed opportunity for correction: Effective communication from the cabin crew could have provided valuable data, possibly averting the wrong decision by the pilots.
The Kegworth air disaster serves as a powerful case study about the importance of getting a just culture right within organisations, where open communication is critical, and errors or near-misses are seen as opportunities for learning and improvement, rather than simply a route for blame and punishment.
The case was extensively analysed in subsequent inquiries and led to changes in training and procedures within the aviation industry. The learning from this incident has become an oft cited example about the critical importance of open lines of communication between all members of operational teams and the far-reaching impact that blame and violation attribution can have.
The decision to ascribe an error and turn it into a learning opportunity or determine that something was a violation is a key factor in people sensing how ‘just’ an organisational culture is.
A new study
A new study by researchers from a range of Indonesian universities and institutions connected to civil aviation and the Indonesian Air Navigation Service Provider looked at how to help managers make the distinction between a genuine error that needs a learning response and one that someone is accountable for.
Findings
The study found that:
- Organisations need to learn, not just from incidents, but also decisions and determinations of culpability. That debriefs need to be held following a determination and the process of decision-making (how it was made and why) is open and communicated to everyone else in the organisation.
- The causes of an incident need to be thoroughly investigated and agreed on before a determination of culpability is made.
- Organisations should have a rubric, like the Five Harmful Behaviours, which distinguishes between:
- Human error – Unintended conduct: where the individual should have done other than they did.
- At risk behaviour – A choice where a risk was not recognised, or was mistakenly believed to be justified.
- Reckless behaviour – Conscious disregard of a substantial and unjustifiable risk of harm.
- Knowledge of harm – Knowingly causing harm (which can sometimes be justified).
- Purpose and intention – where the purpose and intention of the individual was to cause harm – this is never justified.
- There should be a distinction between:
- Minor violations that lead to a verbal or written warning and or some punishment (fine, etc.)
- Medium violations that result in demotion.
- Major violations which could result in removal from a position, suspension, removal from a role (including at the individual’s request) and dismissal.
The main point is that cause needs to be determined first. Did the error occur because the system helped create or enforce the error, or was it human error, and if it was to what extent is the individual culpable. Secondly, the system / organisation needs to learn to make increasingly better decisions, which means the decision process needs to be open to scrutiny and challenge.
Lastly, everyone in a just culture has a role to play in helping make determinations of culpability more effective by voicing their observations if they have any that may influence the process or decision.
In essence, the determination of culpability is a critical part of creating and maintaining a just culture within organisations. By distinguishing between human error, at-risk behaviour, and intentional misconduct, leaders and managers can ensure fair and consistent accountability practices. A robust approach to the determination of culpability not only addresses violations effectively but also creates an environment of trust and continuous improvement. Through clear rubrics, thorough investigations, and open communication, leaders and managers can turn incidents into opportunities for growth and safeguard their culture of fairness and learning.
Primary reference
What is an organisational culture?
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