Anyone with F1 contacts for 'no blame culture' mentality??
Discussion
Totally random post, but a big part of my current job is trying to work out how to improve safety in the NHS. There is a big drive for 'system based' safety investigations, but its a big cultural shift away from 'root cause analysis (otherwise known as finger pointing at stuff or people)'.
It occurred to me watching Toto Wolff explaining no blame culture is essentially what the NHS is trying to do, but with far less engaging language. I would love to see if I can find anyone from F1 to explain their safety/work process to our organisational leadership (16K employees, £1.3billion turn over, not far from Silverstone
), but I have zero contacts or even knowing where to start and didn't know if anyone here could point me in the right direction?
https://www.youtube.com/watch?v=ZoYCyzSjfr0&t=...
It occurred to me watching Toto Wolff explaining no blame culture is essentially what the NHS is trying to do, but with far less engaging language. I would love to see if I can find anyone from F1 to explain their safety/work process to our organisational leadership (16K employees, £1.3billion turn over, not far from Silverstone
), but I have zero contacts or even knowing where to start and didn't know if anyone here could point me in the right direction?https://www.youtube.com/watch?v=ZoYCyzSjfr0&t=...
gangzoom said:
Totally random post, but a big part of my current job is trying to work out how to improve safety in the NHS. There is a big drive for 'system based' safety investigations, but its a big cultural shift away from 'root cause analysis (otherwise known as finger pointing at stuff or people)'.
It occurred to me watching Toto Wolff explaining no blame culture is essentially what the NHS is trying to do, but with far less engaging language. I would love to see if I can find anyone from F1 to explain their safety/work process to our organisational leadership (16K employees, £1.3billion turn over, not far from Silverstone), but I have zero contacts or even knowing where to start and didn't know if anyone here could point me in the right direction?
https://www.youtube.com/watch?v=ZoYCyzSjfr0&t=...
You would be far better served looking at one of the major German or Japanese organisations - when I was co-developing the pilot national approach for this for the DoH / Monitor (as they were) there was extensive engagement via the International Trade Dept with Siemens and Nissan predominantly, but also their significant supply chains too that are held to the same approaches and models of culture. The principles of this have also been taken forward by the DfIT for the medi-city development in China I am involved in modelled on NHS best practice and 'ideal' NHS culture.It occurred to me watching Toto Wolff explaining no blame culture is essentially what the NHS is trying to do, but with far less engaging language. I would love to see if I can find anyone from F1 to explain their safety/work process to our organisational leadership (16K employees, £1.3billion turn over, not far from Silverstone
), but I have zero contacts or even knowing where to start and didn't know if anyone here could point me in the right direction?https://www.youtube.com/watch?v=ZoYCyzSjfr0&t=...
I appreciate that doesn't scratch the itch of being close to an F1 org though.
gangzoom said:
Totally random post, but a big part of my current job is trying to work out how to improve safety in the NHS. There is a big drive for 'system based' safety investigations, but its a big cultural shift away from 'root cause analysis (otherwise known as finger pointing at stuff or people)'.
It occurred to me watching Toto Wolff explaining no blame culture is essentially what the NHS is trying to do, but with far less engaging language. I would love to see if I can find anyone from F1 to explain their safety/work process to our organisational leadership (16K employees, £1.3billion turn over, not far from Silverstone), but I have zero contacts or even knowing where to start and didn't know if anyone here could point me in the right direction?
https://www.youtube.com/watch?v=ZoYCyzSjfr0&t=...
Why not drop Toto an email or write him a letter ?It occurred to me watching Toto Wolff explaining no blame culture is essentially what the NHS is trying to do, but with far less engaging language. I would love to see if I can find anyone from F1 to explain their safety/work process to our organisational leadership (16K employees, £1.3billion turn over, not far from Silverstone
), but I have zero contacts or even knowing where to start and didn't know if anyone here could point me in the right direction?https://www.youtube.com/watch?v=ZoYCyzSjfr0&t=...
In aviation it is known as a "Just Culture" - it's not necessarily "no blame", but it is much more focussed on seeking the systemic failures which lead to the problem rather than pointing the finger at an individual:
https://www.caa.co.uk/general-aviation/the-ga-unit...
The case of Dr Bawa-Garba is a good example of what happens when systemic failures are ignored and an individual is singled out for blame. I would like to think that something similar would not happen in aviation. It is why I tell my daughter (a medical student) that if she ever finds herself in a similar situation she should (a) escalate immediately both by phone and in writing and (b) if appropriate assistance is not forthcoming she should go home sick. Medicine has some huge cultural issues which would not be tolerated in other safety-critical professions.
https://www.caa.co.uk/general-aviation/the-ga-unit...
The case of Dr Bawa-Garba is a good example of what happens when systemic failures are ignored and an individual is singled out for blame. I would like to think that something similar would not happen in aviation. It is why I tell my daughter (a medical student) that if she ever finds herself in a similar situation she should (a) escalate immediately both by phone and in writing and (b) if appropriate assistance is not forthcoming she should go home sick. Medicine has some huge cultural issues which would not be tolerated in other safety-critical professions.
Edited by this is my username on Sunday 14th May 10:17
Edited by this is my username on Sunday 14th May 10:18
Aviation and the military have been trying, with some success, to work within the ‘just culture’ that you describe. This does not absolve an individual or group of their actions but tries to learn from errors.
It is human nature to make errors. However sometime processes create the environment for these errors to go unseen. Add to that violations to published procedures etc, you can have a scenario where you get the wrong outcomes despite the best of intentions.
We also use the substitution test, ie could a similarly trained and qualified individual, make the same error?
It is absolutely not a ‘no blame’ culture but a way of identifying ways of making these errors less likely. Ie, if you have a work around or local norm or procedure for a process, it it a better way of conducting the process? In which case it should be validated and adopted into the certified process. Or does it impact something negatively that that individual or group is unaware of further down stream?
It is also part of a multi pronged approach to encourage reporting within a organisation. There will be numerous near misses for every accidents. Negligence or deliberate damage will still be punished but human error through following process will not. Similarly all individuals at all levels are duty bound to report risk upwards. Ie their manager then owns that risk and is now responsible to act on it or again report upwards.
https://www.icao.int/APAC/Meetings/2018%20APRAST12...
Aviation is pretty good at this, possibly when commercial considerations don’t become too overriding. There are some high profile examples of this, Challenger disaster.
I have a friend, who was very senior in a NHS trust. We have spoken about this but it is a huge cultural shift for those organisations to move away from the ‘march in the guilty man’ response to a mistake.
Aviation does it because a minor error, leaving a tool in an aircraft, can have a fatal and immensely expensive outcome. Arguably the NHS is similar.
This is a diagram as to the thought process.
It is human nature to make errors. However sometime processes create the environment for these errors to go unseen. Add to that violations to published procedures etc, you can have a scenario where you get the wrong outcomes despite the best of intentions.
We also use the substitution test, ie could a similarly trained and qualified individual, make the same error?
It is absolutely not a ‘no blame’ culture but a way of identifying ways of making these errors less likely. Ie, if you have a work around or local norm or procedure for a process, it it a better way of conducting the process? In which case it should be validated and adopted into the certified process. Or does it impact something negatively that that individual or group is unaware of further down stream?
It is also part of a multi pronged approach to encourage reporting within a organisation. There will be numerous near misses for every accidents. Negligence or deliberate damage will still be punished but human error through following process will not. Similarly all individuals at all levels are duty bound to report risk upwards. Ie their manager then owns that risk and is now responsible to act on it or again report upwards.
https://www.icao.int/APAC/Meetings/2018%20APRAST12...
Aviation is pretty good at this, possibly when commercial considerations don’t become too overriding. There are some high profile examples of this, Challenger disaster.
I have a friend, who was very senior in a NHS trust. We have spoken about this but it is a huge cultural shift for those organisations to move away from the ‘march in the guilty man’ response to a mistake.
Aviation does it because a minor error, leaving a tool in an aircraft, can have a fatal and immensely expensive outcome. Arguably the NHS is similar.
This is a diagram as to the thought process.
shirt said:
Complete lol from me and sums up why NHS managers are so good at spunking money up the wall. Some motor racing guy says a thing that sounds good, let’s contact f1 teams rather than look at what is very basic and well established HSE practice.
You might be missing the point here. If HSE says something everyone yawns. When someone like Toto says it - in a positive & engaging way - the message is far more likely to hit homeMaybe, if all the risk exposure you have is climbing the office stairs or making a cup of coffee at lunchtime. For anyone with a job where it is important, not so much. I would hope to god that this includes the nhs.
It’s laughable tbh. Of all the industries and scenarios that could be learned from, but no we saw a guy say a thing on tv and it sounded like a thing we also want to say. Let’s get him in.
It’s laughable tbh. Of all the industries and scenarios that could be learned from, but no we saw a guy say a thing on tv and it sounded like a thing we also want to say. Let’s get him in.
Ridiculous idea it is complete and utter common sense to do this anyway as long as you have the culture and checks in place to ensure bad things do not happen and get out into the customers or public domain. I have worked in 10 person companies who do this far better than an F1 team could ever do.
There are obvious and immense differences between making sure some overpaid petulant kid finishes a race as high as he can or someone receives the right treatment in a hospital.
One does not matter in the slightest to anyone but a few important people due to money.
The other than can have life changing consequences.
There are obvious and immense differences between making sure some overpaid petulant kid finishes a race as high as he can or someone receives the right treatment in a hospital.
One does not matter in the slightest to anyone but a few important people due to money.
The other than can have life changing consequences.
I’ve worked in an organisation that *said* it had a no blame culture. However in reality, it picked and choose when and to who it applied.
In my opinion it said it had a no blame culture just to encourage people to admit mistakes rather than brush it under the carpet. Then they’d throw you under the bus.
The organisation went onto having a model of doing a “test” to see if your error was for personal gain. For example being lazy and cutting corners. If they deemed your mistake was for personal gain, then there definitely was blame. Of course, them f
king up for organisational gain was immune from disciplinary and deficiencies in training or equipment (such as the employer providing adequate lighting at night) were quietly ignored.
Part of me thinks this was just a box ticking exercise just so the management could say they had at least something in place to control errors and risk. Regardless of it even working or even being an honest process. If something happened they had this system, so it must have been the employees fault and not the organisations.
In my opinion it said it had a no blame culture just to encourage people to admit mistakes rather than brush it under the carpet. Then they’d throw you under the bus.
The organisation went onto having a model of doing a “test” to see if your error was for personal gain. For example being lazy and cutting corners. If they deemed your mistake was for personal gain, then there definitely was blame. Of course, them f
king up for organisational gain was immune from disciplinary and deficiencies in training or equipment (such as the employer providing adequate lighting at night) were quietly ignored. Part of me thinks this was just a box ticking exercise just so the management could say they had at least something in place to control errors and risk. Regardless of it even working or even being an honest process. If something happened they had this system, so it must have been the employees fault and not the organisations.
Edited by Mr Miata on Sunday 14th May 18:29
I worked in aviation repair (flight deck instruments) for a while and ther "just culture" was explained to me in great detail. We were told that if you make an error, own up to it quickly. Its better to spot it early and rectify it without causing issues further down the line than cover it up and hope no one notifces. For us, this usually involved something "breaking" when being disassembled and further repairs/spares are requiired. Stripped threads were another. Better to replace the part than fill the hole with threadlock.
Having an aircraft on the ground costs the owner a lot of money, but they would rather have a repair done correctly, than have it rushed and have to spend another unscheduled day on the ground later on.
Having an aircraft on the ground costs the owner a lot of money, but they would rather have a repair done correctly, than have it rushed and have to spend another unscheduled day on the ground later on.
A friend of mine in the F1 industry writes: 'I’m not a member of PH, but if you would be so kind as to point the OP at grid4good
https://www.grid4good.org '
HTH!
https://www.grid4good.org '
HTH!
Mr Miata said:
Part of me thinks this was just a box ticking exercise just so the management could say they had at least something in place to control errors and risk. Regardless of it even working or even being an honest process. If something happened they had this system, so it must have been the employees fault and not the organisations.
NHS England is currently deploying a whole new patient safety strategy to try and change culture, however my biggest worry is actually its very easy to end up in the situation you have described. Producing paper work for 'assurance' is not hard, nor is cheating check lists or endless procedural documents, but without true cultural change its all a wasted effort.I would hate to see any one working in our organisation express the views you have given, if nothing else it would show I have utterly failed in my job role!
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