honest? It is too simple to assert that there should be consequences for those who 'cross the line'. Lines don't just exist out there, ready to be crossed or obeyed. We - people - construct those lines; and we draw them differently all the time, depending on the language we use to describe the mistake, on hindsight, history, tradition, and a host of other factors. What matters is not where the line goes - but who gets to draw it. If we leave that to chance, or to prosecutors, or fail to tell operators honestly about who may end up drawing the line, then a just culture may be very difficult to achieve. The absence of a just culture in an organization, in a country, in an industry, hurts both justice and safety. Responses to incidents and accidents that are seen as unjust can impede safety investigations, promote fear rather than mindfulness in people who do safety-critical work, make organizations more bureaucratic rather than more careful, and cultivate professional secrecy, evasion, and self-protection. A just culture is critical for the creation of a safety culture. Without reporting of failures and problems, without openness and information sharing, a safety culture cannot flourish. Drawing on his experience with practitioners (in nursing, air traffic control and professional aviation) whose errors were turned into crimes, Dekker lays out a new view of just culture. This book will help you to create an environment where learning and accountability are fairly and constructively balanced.

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