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15
Cahit İstikbal
S
idney Dekker begins to her well-
known book “Just Culture” with te
following story:
Keith Ramstead, was a British cardiotho-
racic surgeon settled in New Zealand. While
working as a heart surgeon in New Zealand;
three of his patients dead during surgery
or immediately after surgery. A lawsuit
against Ramstead
began. Not long
before, a profes-
sional colleague had
pointed to serious
deficiencies in the
Ramstead’s work
and found that seven
of his cases had been
managed incompe-
tently. The report
sent to the Police,
this in turn led to the
prosecution against
Ramstead.
Analyzing this
incident, we can end
up with a statement
that if the working climate of Ramstead
was encouraged with ‘Just Culture’ instead
of ‘Blame Culture’; all three manslaughters
could be possibly avoided. Here is how:
R
amstead, made serious flaws
in 7 of his surgeries. We know
this because a colleague of him
noticed that. But there could be
a number of other errors which Ramstead
possibly did and his colleagues did not
notice. Has Ramstead told anbody about
these errors? Or, could other colleagues
take lessons from Ramstead’s errors and
avoided same errors in their own surgeries?
Awidespreading new phenomenon which is
called ‘Just Culture’ answers ‘Yes’ to these
questions.
‘Just Culture’ does not target to provide
an immunity or prevent criminals from pun-
ishment; instead; aims to create a climate in
which professionals are couraged to report
their errors and eventually conditions which
leads to accidents could be prevented.
In recent years, blame culture is also
being questioned by some studies aiming to
prevent accidents. In such studies, the suc-
cess of after-accident processes with regard
to prevent other accident being questioned.
In doing so, one of the key elements used is
the accident pyramid.
Just like the Doctor Keith Ramstead case;
accidents, in fact; comes after a number
of unsafe operations and near miss cases.
Within the climate of blame culture; failing
to create an environment which encourages
reporting of near misses prevent us being
aware of such incidents that leading to acci-
dent. The critical question to be asked here
is that: what is the ideal climate for human
element in which reporting of unsafe opera-
tions and near misses could be encouraged?
How could we create a working environ-
ment which encourages the individual errors
to be reported enabling necessary comments
to be made in order to prevent accidents
arising from them?
Today, there is a full consensus amongst
experts that, it can be not achieved through
an environment of blame culture. Aviation
sector has already passed to Just Culture
from the Blame Culture. Particularly, the
1977 Tenerife disaster in which two 747
jumbo jets collided and 583 passengers lost
their lives was a milestone for change and
today blame culture is an avoided environ-
ment for many carriers.
Today, first steps has already been taken
and a long term period initiated by devel-
oped countries and ‘blame culture’ is being
slowly replaced by the ‘Just Culture’, but
naturally, it will take time.
J
ust Culture does not mean to forgive
the crime. Just Culture; as the name
itself describes; aims to create a work-
ing climate for professionals in which
‘summary execution’ is disallowed. Thus;
the best professional efficiency could be
provided; as well as the possibility of report-
ing and avaluating the near misses which
are the most effective means of preventing
accidents.
What happens if I report this near miss
case? Do I give an inefficient impression?
What do my colleagues say? In a culture
dominated by such ideas, it would be too
optimistic to expect any near miss to be
reported.
From these aspects, "Just Culture" is a
sine-qua-non for the maritime domain; a
phenomenon that should be flourished and
improved. Especially professionals that are
directly related to the safety of life, prop-
erty and the environment such as pilots and
masters very large number of people, need
to work in a climate of Just Culture which
is the most modern component of Safety
Culture. That will eventually result in the
more near miss reports, a psychologically
more comfortable working environment,
and consequently minimize risks and there-
fore will return to us in the form of reduction
of accidents.
n
From “Blame Culture”
to “Just Culture”