Showing results by author "Sidney Dekker" in All Categories

What does the collapse of sub-prime lending have in common with a broken jackscrew in an airliner’s tailplane? These were systems that drifted into failure. While pursuing success in a dynamic, complex environment with limited resources and multiple goal conflicts, a succession of small, everyday decisions eventually produced breakdowns on a massive scale. The growth of complexity in society has outpaced our understanding of how complex systems work and fail. This book explores complexity theory and systems thinking to understand better how complex systems drift into failure.

A just culture is a culture of trust, learning, and accountability. This third edition offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, retributive just culture, and the criminalization of human error. If you learn to look at accountability in different ways, your impact on restoring trust, learning, and a sense of humanity in your organization could be enormous.

Building on its successful predecessors, the third edition of The Field Guide to Understanding 'Human Error' will show a new way of dealing with a perceived "human error" problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call "human error", allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, under the pressure of resource constraints and multiple conflicting goals.

It is hard to change almost a lifetime of your organization’s thinking about safety in the traditional way and it is really difficult to change your organization’s history of bureaucracy that continues to reinforce the traditional safety definitions and metrics our organizations have used for many years. Let’s face it, change even for the better is hard to do. Doing Safety Differently is a discussion between two friends on what they have learned by watching organizations around the world change the way they do work.

There’s been an incident in your organization. People are impacted. You need to do something. How do you avoid blame, and how do you start learning and improving? This book tells you how to respond restoratively; to stay away from flow-chart just cultures that try to match shades of culpability with suitable sanctions. Instead, it invites you to ask what the impacts are of the incident. And what needs to be done to fix those impacts. And whose obligation is it to go do that. If you pursue these questions, you have already begun building a restorative just culture.