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Toolkit

Safety and Justice

Contents
1 Welcome

1.1 Interpreting Human Behaviour

1.2 Welcome

1.2.1 Wizard
1.2.2 About the Toolkit

Welcome
Welcome to the Safety and Justice Toolkit.

This toolkit is designed to be a general purpose utility. It does not exclusively follow one of the many
models about Just Culture that one can find in literature, publications, magazines, websites or
blogs. Where relevant, it points users towards more available material elsewhere. First and foremost,
the toolkit aims to be as practicable as possible and help users determine, or rather, "interpret"
human actions and behaviour during a safety event.

Interpreting Human Behaviour

If you see something go right or wrong in a professional environment it is wise to be deliberate in
how you react.
Advanced users: In the below list, find the level that best matches the observed behaviour. Then
select one of the follow-ups on the same row to see suggestions.
Beginners: If you don't know how to select the correct level, check out the 'general purpose
navigator' (/index.php/Toolkit:Safety_and_Justice/Navigator) first to see how it works.

Welcome
This toolkit supports the interpretation of human behaviour during a safety event. This may help you
in implementing a Just Culture, whereby both accountability and organisational learning are
optimally achieved. The home page shows the interpretor on the left ready for use, but if you want
more information, check out the Welcome (/index.php/Toolkit:Safety_and_Justice/Welcome) pages
and the Theory (/index.php/Toolkit:Safety_and_Justice/Theory) pages first.

Wizard
Need help selecting the right behaviour class?
Apply the Behaviour Navigator (/index.php/Toolkit:Safety_and_Justice/Navigator)

About the Toolkit

This toolkit was developed by Job Brüggen, Safety manager at Air Traffic Control the Netherlands
and Patrick Kools of GoGen - Beyond Rules. For provision of feedback to authors and further
information about using the application on mobile devices visit http://www.safetyandjustice.eu/
(http://www.safetyandjustice.eu/)

Short
Level Direct to examples description of Suggested Just Culture follow u
behaviour

Exceptionally
skillful
handling of a
safety Recognizing exceptional behavio
situation. A just culture, but it is important t
(/index.php/Toolkit:Safety_and_Justice/Baffled)
person really rewarding and HOW you reward
excelled in (/index.php/Toolkit:Safety_and_J
probably a
difficult
situation.

By thorougly
understanding
how the
system works,
a person was
Improving the system effectively
able to
This should be recognised and re
suggest an
individual but also because sets
important
they can apply their expertise an
improvement
improve. Read more >>
(/index.php/Toolkit:Safety_and_Justice/Improving_the_system) to the
(/index.php/Toolkit:Safety_and_J
operations
itself or to the
safety
management
system.

People took
action to help
others
understand
and operate
the system
better. This Becoming a teacher, sharing less
could be milestone in the development of
based on a significant contribution to a safe
self- recognised and rewarded. Read
experienced (/index.php/Toolkit:Safety_and_J
(/index.php/Toolkit:Safety_and_Justice/Teaching_the_system)
 incident or
based on a
known events
in the
organisation
or elsewhere.

Your person
was
demonstrating
skills working Working well with the system sh
the system as Recognising and rewarding this w
it is known. By as a desirable state. If you do no
the book, will see working with the system
intervening Read more >>
(/index.php/Toolkit:Safety_and_Justice/Working_the_system) where (/index.php/Toolkit:Safety_and_J
needed. He
knows his
business!

Somebody
made an error.
These can be
"slips" or
"lapses",
where an
action was
forgotten or First check the Routine test to s

the action First time it happened Read m

was (/index.php/Toolkit:Safety_and
unintentional. The same person did it before
Or it could be (/index.php/Toolkit:Safety_and
(/index.php/Toolkit:Safety_and_Justice/Did_I_do_that) a "mistake", in Everybody does this Read mo
which the (/index.php/Toolkit:Safety_and
wrong
procedure
was applied
(action was
intentional,
follow up was
not).

A rule or
procedure
was not First check the Routine test to s
followed.
First time it happened Read m
Either the rule
(/index.php/Toolkit:Safety_and
was not not
(/index.php/Toolkit:Safety_and_Justice/Say_what) The same person did it before
known, or the
(/index.php/Toolkit:Safety_and
rule was too
Everybody does this Read mo
ambiguous or
(/index.php/Toolkit:Safety_and
complicated
to understand
properly.

Although the
 person knew
about the rule
and the rule
in principle
was workable, First check the Routine test to s
he or she First time it happened Read m
decided that (/index.php/Toolkit:Safety_and
this was not The same person did it before
applicable. (/index.php/Toolkit:Safety_and
Either this Everybody does this Read mo
(/index.php/Toolkit:Safety_and_Justice/I_know_better)
was done to (/index.php/Toolkit:Safety_and
help the
company or
client, or this
could be done
because of
"personal
optimization".

Person knew
there was a
rule and
person knew
Situations like this need to be d
it was not
Read more >>
(/index.php/Toolkit:Safety_and_Justice/F_you) followed, but
(/index.php/Toolkit:Safety_and_J
that suited
you have checked out the Subst
him or her
just fine. Also
known as
"recklessness".

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