4 ms·

This is the first time I've heard of "just culture" and wish it would spread to other areas of the world and life.

gooddeed 3y ago
The ability to drop blame from the equation is a credit to the aviation industry and would drastically improve any team, organisation, or industry to adopt it.
- bertil 3y ago
  When the conference LeadDev happens in London, they often have Nickolas Means give a talk about an aeronautic topic. It’s usually 45 minutes of nail-biting in-depth analysis of a very complicated problem, and ends with a 5 minute rotation to how the lessons from that incident apply to engineering management in general. (You also feel like you could engineer an airplane, but no you can’t: that’s just Nickolas’ talent for explanation that is fooling you. Airplanes are very hard to make.) This is all done in such a smart, seamless, obvious way to deliver a lesson that would make the Brothers Grimm feel cheated. Strongly recommend. https://www.youtube.com/watch?v=2sIzfGzf_50 https://www.youtube.com/watch?v=2sIzfGzf_50 https://www.youtube.com/watch?v=099cHWSbAL8 https://www.youtube.com/watch?v=099cHWSbAL8 https://www.youtube.com/watch?v=4rOPAYoR80M https://www.youtube.com/watch?v=4rOPAYoR80M
- sokoloff 3y ago
  Exactly. When we have an incident, I want us to be very clear about who did what, what they were thinking that led them to that course of action, and the other facts about the incident. Knowing which individual took which action and when is very, very different from holding an individual responsible (in terms of suffering repercussions) from it. If team members trust they won't suffer from it, you get much clearer data, often without even asking for it. Related, I recommend that teams subject to SOX-404 controls consider adopting a variant of FAR 91.3*. Our SOX docs explicitly permit our incident managers (and two additional high-level tech employee roles) to authorize any action they deem justified during a production emergency. * - https://www.ecfr.gov/current/title-14/chapter-I/subchapter-F/part-91/subpart-A/section-91.3 https://www.ecfr.gov/current/title-14/chapter-I/subchapter-F...
- tialaramex 3y ago
  This very specifically works for Accidents - events nobody actually wanted to happen, where we can learn from experience and prevent it happening again. It specifically won't work for things which were not accidents at all, where blame remains a useful tool. There's some nuance, the Captain of the Titanic didn't intend to sink the ship and kill loads of people, in that sense it was an accident - but he also didn't need to head into an ice field at full speed. Various UK politicians didn't set out to drive postmasters to suicide, but they did give political cover to business people they must have suspected weren't being truthful.
  - izacus 3y ago
    Yes, you can even see this in aviation itself - there is still blame put on __poor decisionmaking__ and __violation of rules__. In software I've seen "blameless" mean "people who outright broke the process and in some cases even law should not take any blame".
  - defrost 3y ago
    > the Captain of the Titanic ... Any decent accident investigation should highlight that the Captain was under strict instructions from the ship owners to break a record, wealthy influential owners that could and would destroy his career if he failed to push the ship. Good investigations identify causes with a view to prevent repetition of circumstances. Cases like these (Titanic, UK Post) strengthen the case for whistle blower protection.
    - hef19898 3y ago
      Among other things, the investigation into the Titanic accident gave us the requirement of having enough life boats for everyone and standards in how to evacuate a vessel. Captains being pressured by mamagement / organization to do hazardous stuff is a thing still, in aviation as well as in seafaring.
      - tialaramex 3y ago
        SOLAS (Safety Of Life At Sea) an international convention (ie International Law agreed by most countries) is indeed in big part a result of Titanic. SOLAS covers a lot of safety improvements and has continued to improve over time especially after a later version of the treaty makes updates "tacitly accepted" basically instead of signing treaties periodically the members agree that they're all automatically bound by any changed rules unless enough of them object. SOLAS is handled by IMO, the UN's specialized agency for the sea, which is based in London, on the far side of the Thames not terribly far from Westminster. Unfortunately the thing most people remember (and which you highlighted) is life boats and, perhaps those are actually a bad idea, at least for most ships. Here's how that goes: SOLAS requires life boats, but almost always you won't use them. Titanic is a rare example of a situation where life boats are very useful, an ocean linear breaks apart in the middle of the ocean. In most cases you're not very far from land, and so almost always you just get the people onto land and maybe the ship is damaged/ destroyed or maybe not, that's just stuff and it's insured. Fire? Control the fire, go to port. Hole in the ship? Pumps control sinking, go to port. Engine failure? Tow the ship to port. So in all these cases you don't use the life boats, doing so is basically a last resort. But, even though you would very rarely need them, likely never for a vessel which operates close to shore, they must be maintained periodically because SOLAS, and maintenance of lifeboats is pretty dangerous because they're on the outside of a ship. So you may end up killing or seriously injuring more people by having lifeboats.
ptaipale 3y ago
It's basically the essence of aviation safety work. If one concentrates on blaming individuals, the system is not fixed.
- razakel 3y ago
  Yep, all you've done is created a scapegoat - which in some cases does satiate the public's bloodthirst - but does not actually address the fundamental issues.
ufmace 3y ago
This system does in fact work very well for aviation in the USA. But I think we can't just blindly apply it to everything everywhere, assuming it will work the same. We should be able to consider what cultural factors allow it to work and what might cause it to fail. Among those reasons: * It expects everybody in the organization to be earnest rule-followers doing the best they can to achieve the goals of their organization. The uncaring, reckless, rebellious, etc people have been screened out of the organization long before it gets to that point. * It expects that the whole organization has cultural unity. Nobody is trying to hoard status, power, influence, etc for one subset of the organization at the expense of another. * It expects that the organization as a whole is not, and does not perceive itself to be, under attack from hostile outside forces. Organizations can effectively fear being blamed and destroyed just as well as individuals can.
- filleduchaos 3y ago
  There are and have been plenty of uncaring, reckless and rebellious people in aviation. Part of a just culture is, in fact, efficiently identifying and weeding out such elements as well as building systems that are resilient enough to contain their impact. But of course, it's easier to wring our hands over not having the perfect culture to implement what was itself the culture-builder than to actually put in the decades of work required. As an aside, I think a lot of readers would be better served by setting aside their existing notions of what "blameless" means and looking into what it _actually_ means for the industry in question.

The ability to drop blame from the equation is a credit to the aviation industry and would drastically improve any team, organisation, or industry to adopt it.

bertil 3y ago
When the conference LeadDev happens in London, they often have Nickolas Means give a talk about an aeronautic topic. It’s usually 45 minutes of nail-biting in-depth analysis of a very complicated problem, and ends with a 5 minute rotation to how the lessons from that incident apply to engineering management in general. (You also feel like you could engineer an airplane, but no you can’t: that’s just Nickolas’ talent for explanation that is fooling you. Airplanes are very hard to make.) This is all done in such a smart, seamless, obvious way to deliver a lesson that would make the Brothers Grimm feel cheated. Strongly recommend. https://www.youtube.com/watch?v=2sIzfGzf_50 https://www.youtube.com/watch?v=2sIzfGzf_50 https://www.youtube.com/watch?v=099cHWSbAL8 https://www.youtube.com/watch?v=099cHWSbAL8 https://www.youtube.com/watch?v=4rOPAYoR80M https://www.youtube.com/watch?v=4rOPAYoR80M
sokoloff 3y ago
Exactly. When we have an incident, I want us to be very clear about who did what, what they were thinking that led them to that course of action, and the other facts about the incident. Knowing which individual took which action and when is very, very different from holding an individual responsible (in terms of suffering repercussions) from it. If team members trust they won't suffer from it, you get much clearer data, often without even asking for it. Related, I recommend that teams subject to SOX-404 controls consider adopting a variant of FAR 91.3*. Our SOX docs explicitly permit our incident managers (and two additional high-level tech employee roles) to authorize any action they deem justified during a production emergency. * - https://www.ecfr.gov/current/title-14/chapter-I/subchapter-F/part-91/subpart-A/section-91.3 https://www.ecfr.gov/current/title-14/chapter-I/subchapter-F...
tialaramex 3y ago
This very specifically works for Accidents - events nobody actually wanted to happen, where we can learn from experience and prevent it happening again. It specifically won't work for things which were not accidents at all, where blame remains a useful tool. There's some nuance, the Captain of the Titanic didn't intend to sink the ship and kill loads of people, in that sense it was an accident - but he also didn't need to head into an ice field at full speed. Various UK politicians didn't set out to drive postmasters to suicide, but they did give political cover to business people they must have suspected weren't being truthful.
- izacus 3y ago
  Yes, you can even see this in aviation itself - there is still blame put on __poor decisionmaking__ and __violation of rules__. In software I've seen "blameless" mean "people who outright broke the process and in some cases even law should not take any blame".
- defrost 3y ago
  > the Captain of the Titanic ... Any decent accident investigation should highlight that the Captain was under strict instructions from the ship owners to break a record, wealthy influential owners that could and would destroy his career if he failed to push the ship. Good investigations identify causes with a view to prevent repetition of circumstances. Cases like these (Titanic, UK Post) strengthen the case for whistle blower protection.
  - hef19898 3y ago
    Among other things, the investigation into the Titanic accident gave us the requirement of having enough life boats for everyone and standards in how to evacuate a vessel. Captains being pressured by mamagement / organization to do hazardous stuff is a thing still, in aviation as well as in seafaring.
    - tialaramex 3y ago
      SOLAS (Safety Of Life At Sea) an international convention (ie International Law agreed by most countries) is indeed in big part a result of Titanic. SOLAS covers a lot of safety improvements and has continued to improve over time especially after a later version of the treaty makes updates "tacitly accepted" basically instead of signing treaties periodically the members agree that they're all automatically bound by any changed rules unless enough of them object. SOLAS is handled by IMO, the UN's specialized agency for the sea, which is based in London, on the far side of the Thames not terribly far from Westminster. Unfortunately the thing most people remember (and which you highlighted) is life boats and, perhaps those are actually a bad idea, at least for most ships. Here's how that goes: SOLAS requires life boats, but almost always you won't use them. Titanic is a rare example of a situation where life boats are very useful, an ocean linear breaks apart in the middle of the ocean. In most cases you're not very far from land, and so almost always you just get the people onto land and maybe the ship is damaged/ destroyed or maybe not, that's just stuff and it's insured. Fire? Control the fire, go to port. Hole in the ship? Pumps control sinking, go to port. Engine failure? Tow the ship to port. So in all these cases you don't use the life boats, doing so is basically a last resort. But, even though you would very rarely need them, likely never for a vessel which operates close to shore, they must be maintained periodically because SOLAS, and maintenance of lifeboats is pretty dangerous because they're on the outside of a ship. So you may end up killing or seriously injuring more people by having lifeboats.

ptaipale 3y ago

It's basically the essence of aviation safety work. If one concentrates on blaming individuals, the system is not fixed.

razakel 3y ago
Yep, all you've done is created a scapegoat - which in some cases does satiate the public's bloodthirst - but does not actually address the fundamental issues.

ufmace 3y ago

This system does in fact work very well for aviation in the USA. But I think we can't just blindly apply it to everything everywhere, assuming it will work the same. We should be able to consider what cultural factors allow it to work and what might cause it to fail. Among those reasons: * It expects everybody in the organization to be earnest rule-followers doing the best they can to achieve the goals of their organization. The uncaring, reckless, rebellious, etc people have been screened out of the organization long before it gets to that point. * It expects that the whole organization has cultural unity. Nobody is trying to hoard status, power, influence, etc for one subset of the organization at the expense of another. * It expects that the organization as a whole is not, and does not perceive itself to be, under attack from hostile outside forces. Organizations can effectively fear being blamed and destroyed just as well as individuals can.

filleduchaos 3y ago
There are and have been plenty of uncaring, reckless and rebellious people in aviation. Part of a just culture is, in fact, efficiently identifying and weeding out such elements as well as building systems that are resilient enough to contain their impact. But of course, it's easier to wring our hands over not having the perfect culture to implement what was itself the culture-builder than to actually put in the decades of work required. As an aside, I think a lot of readers would be better served by setting aside their existing notions of what "blameless" means and looking into what it _actually_ means for the industry in question.