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MAKE JUST CULTURE
JUST YOUR CULTURE
It’s not what we believe, it’s what we do, that defines
our culture.
Dan Barker
Chief Architect - Archer
@barkerd427
2
Background
A just culture is a culture of trust, learning and
accountability. - Sidney Dekker
@barkerd427
3
Restorative vs Retributive Just Culture
▪ Restorative
− What needs exist?
− Who’s going to be accountable
− Learning
▪ Retributive
− What happened and who did it?
− Who should have stopped this?
− Blaming
@barkerd427
4
Pathological vs Bureaucratic vs Generative
▪ Power oriented
▪ Low cooperation
▪ Messengers shot
▪ Responsibilities
Shirked
▪ Bridging
discouraged
▪ Failure ->
scapegoating
▪ Novelty crushed
@barkerd427
▪ Rule oriented
▪ Moderate
cooperation
▪ Messengers
neglected
▪ Narrow
responsibilities
▪ Bridging tolerated
▪ Failure -> justice
▪ Novelty ->
problems
▪ Performance
oriented
▪ High cooperation
▪ Messengers
trained
▪ Risks are shared
▪ Bridging
encouraged
▪ Failure -> inquiry
▪ Novelty
implemented
5
6
How Complex Systems Fail
▪ Always in a state of failure
▪ There is no “root cause”
▪ All actions are gambles
▪ Humans are the solution
▪ Change creates new failure modes
@barkerd427
7
“Safety is not the
absence of accidents.
Safety is the presence of
defenses”
Todd Conklin
@barkerd427
8
5 Components of Mindfulness
▪ A constant concern about the possibility of failure
▪ Deference to expertise regardless of rank or status
▪ An ability to adapt when the unexpected occurs
▪ An ability to both concentrate on a specific task
while having a sense of the bigger picture
▪ An ability to alter and flatten hierarchy as best fits
the situation
@barkerd427
9
Why?
▪ Open communication and
transparency decreases litigation
▪ Aviation safety record
▪ Improve outcomes as a byproduct
▪ Potentially increase output
▪ Happier team members
@barkerd427
10
“Start where you are. Use
what you have. Do what
you can.”
Arthur Ashe
@barkerd427
11
Areas where you can help
▪ Enquiry into failure
▪ Information transparency
▪ Cross-functional collaboration
▪ Share responsibilities
@barkerd427
12
Enquiry into failure
▪ Organize a blameless post-mortem
▪ Change your language
− I should have -> I did x and expected
y, but saw z
− Focus on what you will do next
▪ Introduce more feedback
@barkerd427
13
Information transparency
▪ Get information out of email
▪ Open meetings
▪ Finalize decisions asynchronously
▪ Use Slack or Teams
▪ Teach others
@barkerd427
14
Cross-functional collaboration
▪ Invite other functions
▪ Hackathon
▪ Mixer channel on Slack
▪ Make goals cross-functional
▪ Create a dev/ops rotation
@barkerd427
15
Share responsibilities
▪ Make team goals rather than individual
▪ Volunteer to help others
▪ When failure occurs, don’t blame
@barkerd427
16
You play a part in your culture
▪ Influence culture
▪ Be patient
▪ Don’t let the culture hurt you
@barkerd427
17
References
▪ http://sidneydekker.com/wp-content/uploads/2018/12/RestorativeJustCultureC
hecklist.pdf
▪ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1765804/pdf/v013p0ii22.pdf
▪ https://web.mit.edu/2.75/resources/random/How%20Complex%20Systems%20
Fail.pdf
▪ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955339/
@barkerd427
18
Dan Barker
dan@danbarker.codes
danbarker.codes
dan.barker@rsa.com
rsa.com
@barkerd427
Make Just Culture just your culture

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Make Just Culture just your culture

  • 1. 1 MAKE JUST CULTURE JUST YOUR CULTURE It’s not what we believe, it’s what we do, that defines our culture. Dan Barker Chief Architect - Archer @barkerd427
  • 2. 2 Background A just culture is a culture of trust, learning and accountability. - Sidney Dekker @barkerd427
  • 3. 3 Restorative vs Retributive Just Culture ▪ Restorative − What needs exist? − Who’s going to be accountable − Learning ▪ Retributive − What happened and who did it? − Who should have stopped this? − Blaming @barkerd427
  • 4. 4 Pathological vs Bureaucratic vs Generative ▪ Power oriented ▪ Low cooperation ▪ Messengers shot ▪ Responsibilities Shirked ▪ Bridging discouraged ▪ Failure -> scapegoating ▪ Novelty crushed @barkerd427 ▪ Rule oriented ▪ Moderate cooperation ▪ Messengers neglected ▪ Narrow responsibilities ▪ Bridging tolerated ▪ Failure -> justice ▪ Novelty -> problems ▪ Performance oriented ▪ High cooperation ▪ Messengers trained ▪ Risks are shared ▪ Bridging encouraged ▪ Failure -> inquiry ▪ Novelty implemented
  • 5. 5
  • 6. 6 How Complex Systems Fail ▪ Always in a state of failure ▪ There is no “root cause” ▪ All actions are gambles ▪ Humans are the solution ▪ Change creates new failure modes @barkerd427
  • 7. 7 “Safety is not the absence of accidents. Safety is the presence of defenses” Todd Conklin @barkerd427
  • 8. 8 5 Components of Mindfulness ▪ A constant concern about the possibility of failure ▪ Deference to expertise regardless of rank or status ▪ An ability to adapt when the unexpected occurs ▪ An ability to both concentrate on a specific task while having a sense of the bigger picture ▪ An ability to alter and flatten hierarchy as best fits the situation @barkerd427
  • 9. 9 Why? ▪ Open communication and transparency decreases litigation ▪ Aviation safety record ▪ Improve outcomes as a byproduct ▪ Potentially increase output ▪ Happier team members @barkerd427
  • 10. 10 “Start where you are. Use what you have. Do what you can.” Arthur Ashe @barkerd427
  • 11. 11 Areas where you can help ▪ Enquiry into failure ▪ Information transparency ▪ Cross-functional collaboration ▪ Share responsibilities @barkerd427
  • 12. 12 Enquiry into failure ▪ Organize a blameless post-mortem ▪ Change your language − I should have -> I did x and expected y, but saw z − Focus on what you will do next ▪ Introduce more feedback @barkerd427
  • 13. 13 Information transparency ▪ Get information out of email ▪ Open meetings ▪ Finalize decisions asynchronously ▪ Use Slack or Teams ▪ Teach others @barkerd427
  • 14. 14 Cross-functional collaboration ▪ Invite other functions ▪ Hackathon ▪ Mixer channel on Slack ▪ Make goals cross-functional ▪ Create a dev/ops rotation @barkerd427
  • 15. 15 Share responsibilities ▪ Make team goals rather than individual ▪ Volunteer to help others ▪ When failure occurs, don’t blame @barkerd427
  • 16. 16 You play a part in your culture ▪ Influence culture ▪ Be patient ▪ Don’t let the culture hurt you @barkerd427
  • 17. 17 References ▪ http://sidneydekker.com/wp-content/uploads/2018/12/RestorativeJustCultureC hecklist.pdf ▪ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1765804/pdf/v013p0ii22.pdf ▪ https://web.mit.edu/2.75/resources/random/How%20Complex%20Systems%20 Fail.pdf ▪ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955339/ @barkerd427