Under Thinking Just Culture and Accountability

I am definitely capable of over thinking, of tying myself up in knots and being lost in the detail. And other times, I probably haven't thought enough. Recently, I identified just culture as a concept I hadn't really thought about in-depth.

In my mind, I thought I knew what a just culture was. I knew it was more than a simple no-blame policy. I knew it involved establishing what is acceptable and not acceptable behaviour. But that had been the limit of my thinking.

That big void of knowledge started to weigh heavily on my mind. So, I set out to read Sidney Dekker's oft-cited Just Culture. Now that I have finished reading it, that void hasn't been filled - it's a swimming mess of questions, thoughts and more questions.

Although, I think I've got a grasp on that little hard nut called accountability.

I used to talk about how accountability was different to responsibility - "you can delegate responsibility, but you can't delegate accountability". I used to make the distinction that responsibility involved doing things but accountability didn't - "the responsible person performs the action, the accountable person just, ah, is accountable for it". However, I don't think I really ever defined accountability in a meaningful way (save for one occasion, by accident1).

I guess I understood that accountability meant knowing about what was going on in the area for which you were accountable but I never fully digested why that was important and what one would do with that knowledge.

While reading Just Culture had definitely helped me to understand the bigger picture but I don't think my knowledge had synthesised until I begun analysing an uncomfortable incident in which I was involved this weekend.

The Incident

I coach my son's U6 football (soccer) team. We're eight games into the season and I've been slowly gaining confidence in this role with a fair amount of trial and error. There hasn't been a lot of support for newbie coaches but I've been forging my way forward.

During matches, I've been on the field guiding the kids around and encouraging them along as they too fumble through their first year. It has been fun - especially the high-fives I get from four sets of hands for any manner of achievement, everything ranging from scoring a goal right down to not touching the ball with their hands.

But yesterday, things did not go so well.

A couple of minutes in the match, I was setting the ball on the goal line for a kick-in when a man (with no official identification) approached me and advised that I was not permitted on the field during the match. That didn't mesh with my understanding and since I was already concentrating on the match, I brushed  the guy off and told him I was staying on the field. He responded by telling me that he was going to get the ground official.

Not long after, two men wearing high-vis official vests entered the field and instructed the referee to stop the match. One of the men was the man from before, meaning the other must be the ground official. I approached the two men to find out what's going on.

I'll spare you the he said, I said stuff - the final ultimatum was I had to get off the field or he would cancel the match. Not much of a choice really, so I quickly explained the situation to the kids and coached from the sidelines for the rest of the game.

The Post-Incident Analysis

Now, I'm not going to get into all the grubby details of this incident - this post is not about the incident, it's about accountability and just culture.

Since I'm a life-long-learning type of guy, I ran through the incident in my head about a million times yesterday afternoon. I explored issues like:

  • what do they rules actually say? - for the record, I was wrong - I am not permitted on the field during the match;
  • why did I think the way I thought? - primarily a case of confirmation bias;
  • in what ways did these other men act inappropriately or in contravention of policy, etc.?; and
  • chiefly, what can I do better next time?

I thought about all these things as I prepared my incident report for my club president. My incident report, my account by another name. I was accountable for what ever happened on that field, especially incidents directly involving me, and here I was, providing my account.

I imagined the other men were doing the same with both of our club presidents taking these reports and providing their own accounts up the chain, as appropriate.

Okay, now what?

That's a really good question and this is where my past thought process tended to stop.

Dekker makes the point a number of times that sometimes, providing the account is enough. He says that families of patients lost on the operating table are often just wanting to know how it happened from those accountable for the event.

He also mentions the importance of data to learning but I didn't find the connection between learning and accountability that strong in the book. It was only yesterday that that neural pathway was opened.

The push to make people accountable is to increase learning.

Accountable doesn't mean identifying people for punishment, sanction or retribution. It simply means setting an expectation that they will be able to provide an account of what occurs within their sphere of accountability.

And it doesn't relate to just the accountable executive. It relates to everyone. In the above incident, I'm accountable, the other two men are accountable, our club presidents are accountable, the administrators of our local football association are accountable and so on.

This doesn't mean that the president of Football Brisbane should be able to describe the events which took place yesterday off the top of his head. It means that as each of us involved must analyse the incident and identify contributory factors coming from other parties. Those other parties provide accounts of those factors.

For example, why did I think I was allowed on the field? There are a range of contributory factors from inconsistent use of terms surrounding the coaching role both by my club and Football Brisbane right through to never having been corrected during the past eight matches2.

And just as each of us provides an account, each of us must take the accounts of others and learn from the incident. I have obviously learnt that I am not permitted on the field as well as not to trust confirmatory data. I hope that the other men involved learn better techniques for approaching newbie coaches who are concentrating on their teams' enjoyment and I hope that clubs and associations learn a few more ways of providing support for newbie coaches and ground officials.

Justice Served

As fired up as I got yesterday, I don't really think anyone should be punished for what happened. While I would like an apology for the manner of the approach, I am also happy to provide an apology for my frosty reception of the other men's intervention.

Overall, we just need to learn from the incident, move on and see to it that a similar incident doesn't occur again.

How effective that learning is will depend on how far the accounts go. In this instance, it appears that the power of a party to effect wide-spread learning is inversely proportional to the proximity of that party to the original incident3.

What I mean here is that the party furthest away from the incident, say Football Brisbane, has the greatest ability to prevent a repeat of this incident. I'm not going to be involved in this incident again because I now know that I'm not allowed on the field. I hope this incident won't occur at that ground again because the officials involved will adjust their behaviour and I hope that my club will let other coaches now about the incident to minimise it reoccurring within our club. Football Brisbane, on the other hand, has the power to see it and similar incidents prevented with its power to reach all coaches and officials within the Brisbane area and so on.

It's quite amazing what is possible just by providing an account without fear of reprisal. Here's hoping for some communication, some learning and some justice in the very near future.

Now I just wish aviation was as simple as U6 football.

1. I was presenting an SMS course in Indonesia and I had used Google translate taking English into Bahasa Indonesia to try to make the accountability/responsibility discussion more relevant. What I discovered was than in Bahasa Indonesia responsible means to "bear answer" which is pretty close to what I took from Dekker's book as the definition of accountable.

2. Mr Taleb will track me down and spank me for that one. I just read about confirmation bias and the asymmetry in data when it comes to confirmation versus contradiction.

3. I'm not sure if that's original. I can't recall reading it anywhere and it just came to me as I was writing this but that's not to say that I haven't read it before and I'm channelling some great thinker. If that is original, can we please call that the Parsons Rule?